Name:

Email:


Company


Federal Tax ID


Address


City


State


Zip


Phone Number


Cell Phone


Pager Number


Fax Number


Liability Insurance Company


Liability Insurance
Expiration Date

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Have you previously worked for Premier Field Services LLC.?
Yes No

If yes, provide additional information that may be helpful to us:


Do you acknowledge and understand that if you are retained by Premier Fields Services LLC., you will be working as an independent vendor. The completion of this application shall not be construed as creating an employee/employer relationship between you, your company or your employees and Premier Field Services LLC. and its affiliates; that it is the intent of the parties that every vendor/contractor performing work for Premier Field Services LLC. be and remain an independent vendor/contractor and not employees of Premier Field Services LLC.; and that no vendor has the right to receive work from Premier Field Services LLC.; and that work shall be awarded based on performance which is determined on an individual basis?
Yes No

Have you or your company ever been barred from completing HUD work?
Yes No

If yes, please explain:


Do you understand that if work is not completed according to guidelines, Premier Field Services LLC. will correct your invoice to guidelines.
Yes No
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PROPERTY PRESERVATION SECTION

I will charge $ for trip charges.
My Discount Percentage is:
My Photo Rate is: per photo.
My charge for repair bid is:

I am a licensed contractor. Yes No License #:

Please choose the category and subcategory of the type of work that you are interested in doing. Note: you can choose to do more that one type of work for Premier Field Services LLC.

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INSPECTION SECTION

I will charge $ per inspection (collection & drive by).
I will charge $ per RUSH inspection.
I will charge $ per Insurance inspection.
My Photo Rate is: per photo.

Please choose the category of inspections that you/your company are interested in doing. Check all that apply.

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VENDOR BPO's AND APPRAISALS

Are you a licensed Appraiser? Yes No

Are you a licensed Broker? Yes No

Please select BPO or Appraisal if you are interested. Check all that apply.

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I am interested in using the Internet in conjuction with Premier Field Services LLC. work (Recieving work requests, inspections,... and/or sending results, photos,...)
Yes No

Areas Covered
Please list the areas (Zip Code Range, Counties, Cities) that you work in:
Example: 48248-48300, 48089, 48045

Additional Information
Please list additional information that we should be aware of about your services, areas covered and prices that were not covered by the above questions.

For additional information, contact us at (440) 334-7468 or send an e-mail to nickd@premierfield.com

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