Name:_____________________________________________________________________________
Address: __________________________________________________________________________
City/State/Zip: ______________________________________________________________________
Phone: ___________________________________________________________________________
Fax: _____________________________________________________________________________
Email Address: _____________________________________________________________________
Age Range: ________20-29, __________30-39, __________40-49, __________50-59, __________60+
Education: _________________________________________________________________________
Work Experience: ____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Work/Experience related to seniors: _____________________________________________________
__________________________________________________________________________________
Reasons for wanting to be a senior move manager: __________________________________________
___________________________________________________________
Things you like to do best: _____________________________________________________________
Things you like to do least: _____________________________________________________________
General geographical area you wish to serve: _______________________________________________
Personal Strengths: ___________________________________________________________________
Personal Weaknesses: _________________________________________________________________
Personal/Professional goals: _____________________________________________________________
___________________________________________________________________________________
Organizations you belong to: ____________________________________________________________
___________________________________________________________________________________
I attest that the information I have provided is correct to the best of my knowledge.
The undersigned authorized Smooth Transitions, LLC, to make such inquiries by
an independent
agency to verify character, reputation and criminal history.
Signed: ___________________________________________________________
(Print Name) _______________________________________________________
Mail to:
Smooth transitions
601 Briar Hill Road
Louisville, KY 40206-3011