Intake Form – Encore-RV

We are happy that you have decided to join the Encore Team. Please take moment and complete the following form and hit the submit button. This information will always be kept private and will only be used internally by Encore RV. Again, welcome to the team, we’re happy to have you onboard!

Name *

First

Last

Social Security # *

Birthdate *

Mobile Phone *

Home Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #1 *

First

Last

Phone

Relation

Emergency Contact #2

First

Last

Phone

Relation

Doctor Name

First

Last

Phone

Preferred Local Hospital

Medical Conditions / Prescription Medications / Allergies

Please list any medical conditions, prescription medications, and allergies that we may need to be made aware of in the event of an emergency.

Encore Benefits - Please Check the Box of the Benefits You Plan to Take *

Medical Insurance
Dental Insurance
Vision Insurance

By checking the boxes above, you are NOT entitled to take the insurance, this is only to provide additional information. Each employee receives at no cost a $20,000 life insurance policy with an additional $20,000 accidental death policy

Authorization *

I have voluntarily provided the above information and authorize Encore RV, LLC and its representatives to contact any of the above on my behalf in the event of an emergency.

Signature

Clear Signature