Independent Contractor Application

Name/Company Name:     Date:

Sole Proprietor:     Partnership:     Corporation:     SSN:     EIN:

Address:     

City:    State:     Zip Code:

Business Phone:     Business Fax:     Cell Phone:

Web Address:     E-Mail:

Business Information

How long have you been in business?     Do you have a full time office staff? Yes No

What are your office hours?     Do you employ subcontractors? Yes No

How many subcontractors are currently working for you?

How is work distributed to your subcontractors:

Web Site     E-Mail     Fax Machine     Postal Mail     Picked Up     Other

Do you have or have access to the following:

Computer Yes No     Laptop Yes No     Internet Connection Yes No    Air Card Yes No

Fax Machine Yes No     Pick up Truck Yes No     Trailer Yes No

Do you carry Liability Insurance? Yes No     Policy Amounts:

Company Insurance is through:

Please provide three business related references:

Company:

Contact Person/Position:

Phone Number:

Length of Service:

Company:

Contact Person/Position:

Phone Number:

Length of Service:

Company:

Contact Person/Position:

Phone Number:

Length of Service:

Scope of Services Performed: