Position of interest: Specific Contract # *** Other VIEW AVAILABLE OPPORTUNITIES
Which area would you like to work? Not Specified ALABAMA Auburn, AL Birmingham, AL Dothan, AL Florence, AL Gadsden, AL Huntsville/Decatur, AL Madison, AL Mobile, AL Montgomery, AL Tuscaloosa, AL FLORIDA Daytona Beach, FL Deltona/DeLand, FL Ft. Lauderdale/Hollywood, FL Ft. Myers/Cape Coral, FL Gainesville, FL Lake City, FL Lakeland, FL Jacksonville, FL Melbourne/Palm Bay, FL Miami, FL Naples, FL Ocala, FL Orlando, FL Panama City, FL Pensacola, FL Port St Lucie/Ft Pierce, FL Sarasota/Bradenton, FL St. Augustine, FL St Pete/Clearwater, FL Tampa, FL Tallahassee, FL Titusville, FL West Palm Beach/Boca Raton, FL GEORGIA Albany, GA Atlanta, GA Athens, GA Augusta, GA Brunswick, GA Carrollton, GA Columbus, GA Gainesville, GA La Grange, GA Hinesville, GA Macon, GA Rome, GA Savannah, GA Thomasville, GA Valdosta, GA KENTUCKY Bowling Green, KY Covington, KY Henderson/Owensboro, KY Hopkinsville, KY Lexington, KY Loiusville, KY Paducah, KY LOUISIANA Alexandria, LA Baton Rouge, LA Houma, LA LaFayette, LA Lake Charles, LA Monroe, LA New Orleans, LA Shreveport, LA MISSISSIPPI Greenville, MS Gulfport/Biloxi, MS Hattiesburg, MS Jackson, MS Meridian, MS Tupelo, MS Vicksburg, MS NORTH CAROLINA Asheville, NC Charlotte, NC Concord/Kanapolis, NC Greensboro, NC Greenville, NC Fayetteville, NC Hickory, NC Raleigh/Durham, NC Rocky Mount, NC Winston-Salem, NC Wilmington, NC SOUTH CAROLINA Aiken, SC Anderson, SC Columbia, SC Charleston, SC Florence, SC Greenville, SC Hilton Head, SC Myrtle Beach, SC TENNESSEE Chatanooga, TN Clarksville, TN Cookesville, TN Jackson, TN Johnson City, TN Knoxville, TN Memphis, TN Nashville, TN Shelbyville, TN
Have you ever inquired about an independent contractor position before? *** Yes No
If you were referred to CCI by an existing contractor, who referred you?
PERSONAL INFORMATION
ZIP
DRIVING HISTORY
What type of Drivers License do you currently have? Issued in what state?
How many accidents have you been involved within the previous 5 years? Nothing Selected 0 1-2 3-5 6 or more
How many claims have you presented to YOUR insurance company in the last 5 years? Nothing Selected 0 1-2 3-5 6 or more
PREVIOUS CONTRACT REFERENCES
Are you currently serving other clients? Nothing Selected Yes No
List Previous Independent Contractor positions, starting with most recent.
Date of Contract
Are you/your company bondable? Nothing Selected Yes No
Have you/your company ever filed for bankruptcy? Nothing Selected No Yes
Have you ever been convicted of a felony? Nothing Selected No Yes
Are you willing to submit to a drug screen? Nothing Selected Yes No
What equipment do you use for your business:
Vehicle Year Vehicle Make Vehicle Model
Our clients require that our independent contractors carry a minimum of $100,000 per occurrence in Liability Insurance.
What levels of insurance do you currently have? Nothing Selected 100k/300k 50k/100k 25k/50k 10k/20k Other
If you do not currently carry the required amount, are you willing to update your policy to the required levels? Nothing Selected Yes No
Please review your information before submitting for accuracy. Because this form is being submitted via a server that is not secure, Social Security Numbers, FEIN Numbers and/or Driver License Numbers are not being requested. If contacted based on the information provided via this form to further discuss contracting opportunities with CCI, you will be asked to complete a standard CCI Data Sheet.
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2. if contracted, your contract will be for no definite period of time and regardless of the date of payments, your contract may be terminated at any time without prior notice.