American Expediting Company
Independent Contractor Application


Date: Social Security #:   
Last Name: First Name: MI:
Present Address
Street:      
City: State: Zip:
County:      
Permanent Address
Street:      
City: State: Zip:
County:      
Phone      
If related to anyone in our company, state name and department (include name of spouse)
Name:Department:Referred by:
Education
School Name, City, State GraduatedSubject Studied
Grammar SchoolYN
High SchoolYN
CollegeYN
Trade, Business
or Correspondence
School		YN
Former Employers (List below last four employers, starting with last one first)
DateName and Address
of Employer		SalaryPositionReason for Leaving
*The Age Discrimanation in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are 40 years of age or older.
References (List below the names of three persons not related to you, whom you have known at least one year.)
NameAddressBusinessYears
Acquainted
In case of emergency notify
NamePhone

Have you ever been convicted of any criminal offense other than minor traffic violations?

Yes No

If yes, list all convictions.
Charge Result City, State of Conviction Date of Conviction
1.
2.
3.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISAPPROVAL. FURTHER, I UNDERSTAND AND AGREE THAT MY STATUS IS THAT OF AN INDEPENDENT CONTRACTOR AND AS SUCH, I AM RESPONSIBLE FOR ALL TAX LIABILITIES PERTAINING TO MONIES RECEIVED IN THE COURSE OF SERVICES I PERFORM.