Check All That Apply:

Bicycle Foot Motorized

Bonus Code (if provided to you):

Your Last Name:

Your First Name:

Your Middle Initial*:

Name that you use for your courier business:

Street Address Line 1:

Street Address Line 2:

City:

State:

ZIP Code:

TELECOMMUNICATIONS:(please include area codes)

Home Phone:

Nextel Phone:

(If available)

Nextel Private ID#:

(If available)

Alternative Mobile Phone:

Pager:

E-mail Address:

BUSINESS INFORMATION:

Social Security Number or Federal EIN:

Operating Region:

Transport Vehicle Type:

Number of years of experience as a courier:

None 1 Year 2 Years 3 Years 4 Years 5-10 Years 11+ Years

Please provide the name of the company that you have done the most amount of courier work for (if applicable):

Availability:

35-60 hours per week 10-34 hours per week

availability:

Weekdays Only Weeknights Only Weekends Only Weekdays and weeknights Weekdays, weeknights and weekends

Country of Citizenship

United States of America Canada Mexico Other

Highest level of education:

No degree High School Diploma 2 Years of College 4 Year College Degree Post-graduate Degree

Have you ever been convicted of a felony?

Yes No

How did you learn about us?

Newspaper Advertisement Sign Radio Google.com Internet, other than Google Referral Other

If you heard about us from someone else (a referral), please let us know the name of the person who told you about us:

BUSINESS REFERENCES: Please provide us with commercial business references that you have worked with. You should include companies that you have had an affiliation within the past 5 years:

Business Reference 1:

Name of Business:

Nature of Relationship:

Month and Year Affiliation Began:

January February March April May June July August September October November December 2003 2002 2001 2000 1999 1998 1997 Earlier than 1997

Month and Year Affiliation Ended:

January February March April May June July August September October November December 2003 2002 2001 2000 1999 1998 1997 Earlier than 1997

Name of person worked closely with:

Phone Number:

(Include area code)

Business Reference 2:

Name of Business:

Nature of Relationship:

Month and Year Affiliation Began:

January February March April May June July August September October November December 2003 2002 2001 2000 1999 1998 1997 Earlier than 1997

Month and Year Affiliation Ended:

January February March April May June July August September October November December 2003 2002 2001 2000 1999 1998 1997 Earlier than 1997

Name of person worked closely with:

Phone Number:

(Include area code)

Business Reference 3:

Name of Business:

Nature of Relationship:

Month and Year Affiliation Began:

January February March April May June July August September October November December 2003 2002 2001 2000 1999 1998 1997 Earlier than 1997

Month and Year Affiliation Ended:

January February March April May June July August September October November December 2003 2002 2001 2000 1999 1998 1997 Earlier than 1997

Name of person worked closely with:

Phone Number:

(Include area code)

EMERGENCY CONTACT: Please provide info on a contact person in case of an emergency:

First and Last Name of Contact:

Nature of Relationship:

Home Phone Number:

(Include area code)

Cell or Mobile Phone Number:

(Include area code)

Work Phone Number:

(Include area code)