Name:

Fictitious Business Name:

Business Address:

City:

Zip:

Business Phone:

Business Fax:

Evening Phone:

Cell Phone:

Email:

Employer Identification Number:
Or Social Security #:

Form of business entity:

Do you hold a professional license? Please list.

Do you have a business license? Yes No

Describe the training that you have received in your specialty and services that you perform.

Please list your general liability insurance carrier:
Policy number:

Please list your auto insurance carrier:

Provide the name of a few companies for which you have performed services as an independent contractor for the past two years.

How do you market your services? (Explain below)

Describe the business expenses you pay now including office or workplace rental, materials and equipment expenses, telephone and other expenses:

Have you ever hired employees? Yes No
If “yes” Have you paid federal and state payroll taxes for your employees?
Yes No

If you have hired employees, please provide the following:
Name of workers compensation insurance carrier:

Workers compensation policy number:

Please indicate if you are in the process of getting licensed or obtaining insurance and when you will be obtaining them. Explain below

Please list all of the service areas/cities that you currently provide service in, as well as service areas/cities that you will provide service in.