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Phone Number

C.J. Grant Marketing, LLC

Contractor Application

* Fields are Mandatory

Contractor's Full Name:

General Manager:

Client:

Location:

How did you hear about us?

Craigslist

Newspaper Ad

Referral

If yes, list the referrer's name

Other:

Manager Checklist

Contractor Information (3 Pages)

Background Release Form (1 Page)

Independent Contractor Agreement (7 Pages)

Contractor Integrity Pledge (1 Page)

W-9 Form (4 Pages)

Direct Deposit or Pay Card (1 Page)

Driver License

Social Security Card

Photo

Date:

(MM/DD/YYYY)

Contractor Information

Position:

Name: (First)

(Middle) (Last)

Present Address:

Home Telephone:

Other Telephone:

Social Security Number:

- -

Date of Birth:

(MM/DD/YYYY)

Email Address*:

Have you ever worked or contracted with C.J. Grant Marketing before?

Yes No

If yes, give dates:

(MM/DD/YYYY)

Do you have a valid driver's license?

Yes No

Do you have proof of insurance (50/100/50 minimum)?

Yes No

Can you present evidence of your identity and eligibility to work in the US?

Yes No

If yes, are there any restrictions on your eligibility to work in me US?

Yes No

Have no ever been convicted of a misdemeanor or felony?

Yes No

If yes, state the nature of the crime(s), when and where you were convicted, and the disposition of the case:

* Disclosure of criminal convictions will not disqualify an applicant from consideration of contracting with C.J. Grant Marketing.

Emergency Contacts:

Please list the name of an individual you wish for us to contact should there be an emergency:

Signature - Read and Initial Before Signing

I certify that all of my statements and information I have provided herein are true, complete, and correct. I also understated that any misrepresentation, falsification, omission, or misleading statements herein (and in accompanying resume, if any) is grounds for the immediate termination of the contract agreement with C.J. Grant Marketing, regardless of the time elapsed before discovery of the statements.

I agree to immediately notify C.J. Grant Marketing if I am convicted of a felony, or any crime involving dishonesty, breach of trust or violence during the period of contract. For positions requiring a valid driver's license, I agree to immediately notify Management if I lose my right to drive during the period of contract.

In order to assist C.J. Grant Marketing in conducting a background check, I authorize the company to investigate my work history, educational background, criminal history, personal references, credit record, driving record and proof of liability insurance. I further authorize any present or former employer or contracting company, educational institutions, personal reference, public agency, or other person or entities contacted by the Company disclose to it upon request any information they may have about me. I release any such persons or entities from any and all liabilities for disclosing such information to the company.

I understand that nothing contained in this form is intended to create a contract between me and C.J. Grant Marketing. No promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the President of the Company or his agent.

C.J. Grant Marketing is a drug-free workplace. All offers to join C.J. Grant Marketing, including those considered for rehire, are contingent upon the successful completion of a drug test. Positive or abnormal results for prohibited drug use will make me ineligible to join C.J. Grant Marketing.

Print Name:

Signature:

Date:

(MM/DD/YYYY)

BACKGROUND CHECK RELEASE FORM

Contractor's Full Name:

Social Security Number:

Date of Birth:

Driver's License Number & State:

Address:

City, State, Zip:

Phone:

General Manager:

Office:

Client:

City:

In order to assist C.J. Grant Marketing, LLC (the "Company") in conducting a background check as initialed below:

I authorize any public agency, or other person or entities contacted by the Company to disclose any information they may have about me. I release any such persons or entities from any and all liabilities for disclosing such information to the Company.

I authorize the Company to investigate my criminal history and verify my Social Security number.

I authorize the Company to investigate my driving record for positions that require driving on the job.

I acknowledge that C.J. Grant Marketing is a drug-free workplace. All offers of employment or contracting agreements are contingent upon the successful completion of a drug test. Positive or abnormal test results for prohibited drag use will make me ineligible to join C.J. Grant Marketing.

I understand that nothing contained in this form is intended to create a contract between me and C.J. Grant Marketing. No promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the President of the Company or his agent

By signing this form, I authorize C.J. Grant Marketing to conduct the above mentioned checks. I verify that all of the information I have provided herein is true, complete, current and correct

Applicant signature:

Date:

(MM/DD/YYYY)