(Independent Contractor)

Please fill out this information in its entirety to the best of your ability.

Position of interest:  Specific Contract # VIEW AVAILABLE OPPORTUNITIES

Which area would you like to work?

Have you ever inquired about an independent contractor position before? 

If you were referred to CCI by an existing contractor, who referred you?


Company Name
Your Name
Street Address Apt #


Home Phone Cell Phone
Pager or FAX E-mail


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?

How many claims have you presented to YOUR insurance company in the last 5 years?


Are you currently serving other clients?   

List Previous Independent Contractor positions, starting with most recent.


Date of Contract

Company Name City/State Phone Brief Description of Contract
From: To:

Are you/your company bondable?  

Have you/your company ever filed for bankruptcy?  

Have you ever been convicted of a felony?  

Are you willing to submit to a drug screen?  

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?

If you do not currently carry the required amount, are you willing to update your policy to the required levels?

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.

By clicking on the Send button below you are electronically signing this form and stating that you understand:

1.    any misrepresentation or omission of facts requested in this form is cause for immediate cancellation of contract, if contracted and

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.