PO Box 1281
South Bend, Indiana 46624
Phone: 574-243-1907
Fax: 574-243-0917
E-Mail:
employment@amconnections.com
MEMBER:
INDEPENDENT CONTRACTOR INFORMATION
Name:
Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
EDUCATIONAL BACKGROUND:
SELF-EMPLOYMENT EXPERIENCE:
Grade School:
1:
Address:
Phone:
Yrs Completed:
High School:
2:
Address:
Phone:
Yrs Completed:
College:
1:
Address:
Phone:
Yrs Completed:
REFERENCES
Name:
Address:
Phone:
Relationship:
1.
2.
3.
ADDITIONAL QUESTIONS
1. Do you have dependable transportation?
YES
NO
2. Do you have pressing obligations that would prevent you from being dependable?
YES
NO
I understand that AM Connections engages demonstrations on a per-job contract basis and pays monthly for all work done in the previous month. I have completed the above information honestly and to the best of my ability.
Signature:
Date:
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