Independent Contractor Information

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This information is used for classification purposes and does not affect consideration for an opening. Your personal information will be kept strictly confidential. Only approved Quality employees will be allowed access to this information. This information will not be shared with anyone.

General Information

First Name
Last Name
Address
City
State		Zip
Social Security #
Date of Birth
E-mail
Home Phone
Best time to reach at home
Work Phone
Best time to reach at work
Fax number

Personal Information

Sex:	Male Female

Race:	African American Hispanic Native American White Other *If other

Marital Status:	Single Married Divorced Widowed

Education Level:	High School Part College College Post Graduate

Current Employment:	Full Time Part Time Type of Work

Spouse Employment:	Full Time Part Time Type of Work

Employment History

1.	Company Name:
	City/ST:
	Contact & Phone:
	Positions:

2.	Company Name:
	City/ST:
	Contact & Phone:
	Positions:

Shopping Information (answer where applicable)

1. How far are you willing to travel?	1-10 miles 11-25 miles 25-50 miles 50+ miles
What is the largest city near you?

Car make/model/year:
Current approximate mileage:

2. Do you wear:	Glasses Contacts None

3. Have you ever rented to own furniture, appliances, or electronics?	Yes No *If yes, experience and company:

4. Do you live in a:	House Apartment

5. Do you shop for clothes? If so, where?

6. Do you shop for furniture? If so, where?

7. Do you shop for appliances? If so, where?

8. Do you shop for electronics? If so, where?

9. Do you use a camera:	Regularly Occasionally Never
What kind?	35mm Auto Video

10. Do you rent movies:	Weekly Bi-weekly Monthly Occasionally Never

11. Do you own a hand held tape recorder?	Micro Regular None

Please summarize a recent shopping experience: