INDEPENDENT CONTRACTOR QUESTIONNAIRE
Date: Available Start Date:
Name:
Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:
Phone # Cell Phone #
Drivers License # State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Expiration Date:
Vehicle
Make: Model: Year: 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Other Type: Car Truck Bobtail Flatbed Other
Equipment - Do you own?:
Mapsco for: No Yes Dallas No Yes Ft. Worth
Two Wheeler (dolly): No Yes Pallet Jack: No Yes Tie Down Straps: No Yes Load Locks: No Yes
Topper: No Yes Lift Gate: No Yes Cargo Net: No Yes
Previous Work Experience
Dates
Company
Salary
Position
Reason For Leaving
References
Name
Phone Number
Years Known
By submitting this form, "I certify that the facts contained in this questionnaire are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein and the references and companies listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information."
