Independent Contractor Application Form

Date

Full Name

Social Security

Address

Cell Phone

Email Address

High School

Diploma

• Yes
• No

GED

• Yes
• No

College

Did you graduate?

• Yes
• Not yet

Experience pertaining to job:

Former Employee

Salary

Position

Reason For Leaving

When did you start

When did you leave

Availability (Please write in when you are available to work)

Monday Hours (from - to)

Tuesday Hours (from - to)

Wednesday Hours (from - to)

Thursday Hours (from - to)

Friday Hours (from - to)

Saturday Hours (from - to)

Sunday Hours (from - to)

When are you available to start working?

Do you have a car or reliable transportation?

• Yes
• No

Are you willing to pay for necessary training?

• Yes
• No

You are required to have a Live Scan II Background Screen for this position, are you willing to pay for this?

• Yes
• No

How far are you willing to travel for work? (check below)0-15 miles15-30 milres30-50 miles

Professional Reference #1

Address of Reference

Phone Number of Reference

Years known

Professional Reference #2

Address of Reference

Years known

AUTHORIZATION “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contain herein and the references and employers 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 in from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by and authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner pro-habited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

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