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Contractor/Agent Application

Date *

Full Name *

Year of Birth *

Phone Number *

Cell Phone Number

Email *

Address *

City *

State *

Zipcode *

FED TAX ID# *

COMPANY NAME (IF INCORPORATED)

IC contractors please describe any transportation delivery driving history and how many years of experience you have related to the delivery industry. Send a copy of your driving record obtained in the last 30 days from your state DMV agents applying please include any airport codes you provide services from and to. *

Vehicle Information

Vehicle Type *

Make *

Model *

Year *

License Plate # *

VIN # *

Insurance Company *

Please provide current certificate of insurance for auto policy.

Work History

List two companies you have contracted with to provide delivery services.

First Contract

Company Name *

Position *

Contact Number *

Contact Name *

Dates Worked:

From *

To *

Type of contracted work ie. on-demand, routed, medical route, distribution, white glove (assembly), fulfillment, airport delivery (tsa) or other (please explain). *

Second Contract

Company Name *

Position *

Contact Number *

Contact Name *

Dates Worked:

From *

To *

Type of contracted work ie. on-demand, routed, medical route, distribution, white glove (assembly), fulfillment, airport delivery (tsa) or other (please explain). *

To the best of my knowledge the above information is accurate and truthful. I understand that I am completing this information in order to contract my services as a self-employed independent contractor and not as the employee of any company.

Independent Contractor *

Date *

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Contractor/Agent Application

Vehicle Information

Work History

First Contract

Dates Worked:

Second Contract

Dates Worked:

Contact Our Freight Delivery Services Company

Contact

Disclosures

Contractor/Agent Application

Vehicle Information

Work History

First Contract

Dates Worked:

Second Contract

Dates Worked:

Contact Our Freight Delivery Services Company

Contact

Disclosures

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