Sub Contractor’s Form Company / Business Name DBA (if any) Owner / Primary Contact Name Title/Role EIN / SSN (as applicable) Business Address City State ZIP Phone (primary) Alternative Phone Email Alternative Email Website Years in Business Number of Employees / Subcontractors Scope of Work / Services Offered Are you an independent contractor? Yes No Do you carry general liability insurance? Yes No Insurer Policy # Expiration Limits: General Liability $ Auto Liability $ WC $ Do you carry Workers’ Compensation? Yes No (If not, explain) Contractor license number (if applicable) Issuing state Expiration W-9 attached? Yes No Do you have vehicles used for work? Yes No If Yes — list each vehicle Vehicle 1 Make/Model Year Type (pick/van/box truck/etc) License Plate / State VIN (last 4) Vehicle 2 Make/Model Year Type License Plate / State VIN (last 4) Will you use these vehicles to transport employees/equipment? Yes No Do you or employees driving on our projects have valid driver’s licenses? Yes No Driver name(s) and license number(s) (or attach list) Authorize Motor Vehicle Record (MVR) check? I authorize Top Notch Tidy LLC to obtain an MVR. (Initial: ___) OSHA/SSP/Other safety training completed? List certifications and dates Do you have written safety programs? Yes No Drug testing policy? Yes No Preferred billing terms (Net 30 / Net 15 / COD / Other) Billing contact Billing Email Typical lead time to start a contract Attachments Checklist (please attach) Certificate of Insurance (COI) with Top Notch Tidy LLC listed as additional insured (if required) W-9 form Contractor License (if applicable) Copy of Driver’s License(s) for drivers listed Vehicle registration(s) Resume or company capability statement / work photos Safety program & relevant certs Agreements & Authorizations (please read): By signing below I certify that all information is true and complete. I authorize Top Notch Tidy LLC to verify the information provided, contact references, obtain motor vehicle records and background checks for listed drivers and personnel as necessary, and request proof of insurance. I understand that providing false information may lead to contract termination. Title Signature Date For internal use: Submit
