First Name: Last Name: MI
Address:
City: State: Zip Code:
Home Phone: Business Phone: Cell Phone:
Have you ever contracted to Pace Runners before? Yes No
Would you like to contract to Pace Runners Full-Time Part-Time or As Needed?
CONTRACT / WORK EXPERIENCE: (Please list most recent first)
Company/Employer Name:
Company Address:
City: State: Zip:
Contact:
Were you a contractor or employee?
May we contact? Yes No
Reason you no longer have a relationship with this company
VEHICLE INFORMATION:
Make: Model: Compact Full Size Station Wagon SUV Mini Van Cargo Van Pick Up Truck Model Year: Is vehicle insured? Yes No
If no, would you be willing to insure your vehicle for the limits required by the state of Alabama? Yes No
Would you be willing to add Pace Runners as a co-insured on your vehicle? Yes No
BUSINESS INSURANCE:
Do you carry workers compensation insurance? Yes No
If no, would you be willing to secure workers compensation insurance or allow Pace Runners to supply it to you and deduct it from your settlement check? Yes No
MEDICAL INFORMATION / DRUG SCREENING
In order for Pace Runners to enter into an independent contractor agreement with you, we require that you have a medical card or be willing to have a medical examination as well as a drug screening. If you do not have a current medical card, would you be willing to take a physical examination? Yes No
Would you be willing to take a drug screening? Yes No
Upon completion of this questionnaire, we will make a determination as to whether you meet the qualifications necessary to contract to Pace Runners. Should we determine that we would like to enter into an agreement with you, would you be willing to sign a formal independent contractors agreement? Yes No
Thank you for your time.
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