Position of interest: Specific
Which area would you like to work?
Daytona Beach, FL
Ft. Lauderdale/Hollywood, FL
Ft. Myers/Cape Coral, FL
Lake City, FL
Melbourne/Palm Bay, FL
Panama City, FL
Port St Lucie/Ft Pierce, FL
St. Augustine, FL
St Pete/Clearwater, FL
West Palm Beach/Boca Raton, FL
La Grange, GA
Bowling Green, KY
Baton Rouge, LA
Lake Charles, LA
New Orleans, LA
Rocky Mount, NC
Hilton Head, SC
Myrtle Beach, SC
Johnson City, TN
Have you ever inquired about an independent contractor position before?
If you were referred to CCI by an existing contractor, who
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?
6 or more
How many claims have you presented to YOUR insurance company
in the last 5 years?
6 or more
PREVIOUS CONTRACT REFERENCES
Are you currently serving other
List Previous Independent
Contractor positions, starting with most
Date of Contract
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
Our clients require that our independent
contractors carry a minimum of $100,000 per occurrence in
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.
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misrepresentation or omission of facts requested in this form is cause for
immediate cancellation of contract, if contracted and
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.