Premier Property Group of Volusia County Vendor Application Form

The following information on this page is required in order to process the application

Vendor's Company name *

Vendor's Full Name *

Vendor's Other last names *

Vendor's Nicknames *

Vendor's Home Phone *

Vendor's Work Phone *

Vendor's Cell Phone *

Vendor's Birth date *

Vendor's Tax ID *

Vendor's Social Security Number *

Vendor's Driver's License Number *

Upload Driver's License *

Allowed File Types: JPG/JPEG, PNG, PDF, DOC/DOCX

What type of work does your company do? Please fill out detail on the following lines *

Please answer all of the following questions

Do you have email *

Yes

Email *

Do you have a fax? *

Yes

List Fax # *

Do you have a cellular phone? *

Yes

Cellular # *

Do you have a contractor’s license? *

Yes

License # *

Do you have a current bond? *

Yes

Bonding Company *

If so, how much do you carry? *

Do you carry current business/liability insurance? *

Yes

Insurance Company *

If so, amount of liability *

Do you have employees? *

Yes

Do you use other licensed contractors? *

Yes

Do you carry current workman’s comp *

Yes

Workman's Comp Company *

Will you allow a credit check on yourself and/or your company? *

Yes

Will you agree to a drug-free policy?

Yes

Do you have a reliable and reasonable vehicle for work? *

Yes

Please list four references below *

Name - Relationship - Phone Number

I, the UNDERSIGNED APPLICANT, affirm that the information contained in this application is true and correct, and I authorize (Company Name), to verify all information contained in this application. Misstatements, either false or incorrect are reasons for denial of application. I authorize (Company Name) to run a credit report on myself and/or my company.

Vendor's Signature

Clear

Date *