Application For An "Isp" Independent Service Provider & Irs Form W-9 & Njs Verification Form
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1
2
3APPLICATION for an "ISP"
INDEPENDENT SERVICE PROVIDER
COMPANY INFORMATION
Company Legal Name
Federal Tax ID #
Company DBA
Business License State
Owners Name(s)
Business License ID #
Physical Address
(if
Mailing Address
different)
Telephone #
Fax #
Mobile Phone #
Other Phone #
Authorized Contact Name
# of Employees
Company Web Address: www.
Annual Payroll $
Email(s)
Emergency Services Contact Name
Emergency #
PLEASE ANSWER THE FOLLOWING QUESTIONS
YES
NO
1. Have you or your company ever filed for bankruptcy?
2. Within the last three years, has your company been named as a defendant in any lawsuit(s) or charges/ complaints,
including those filed by or for customers, or employees of your customers?
3. Have you ever been a party either personally or part of a company, or as a company owner, to any wage and hour
or unfair labor practice cases, class action suits, or currently a defendant in any lawsuit?
4. Do you and your company comply with the Immigration Reform and Control Act (IRCA)?
5. Are you in compliance with all local, state and federal wage and hour regulations?
6. Do you self perform in the selected services?
7. List two retail references
(name/phone/email):
SELECT THE TYPES OF SERVICE(S) YOUR COMPANY PROVIDES
(check all that apply)
Janitorial
Windows
Hard Floors
Other
(indicate below)
Daily
Standard
Construction Cleaning
High
Escalator Cleaning
Restoration
Water Extractions
Carpet Cleaning
Power Washing
Emergency Services
High Dusting
Awnings
YOUR SERVICE AREA LOCATIONS BY ZIP CODE
Separate each by a comma and attach additional sheet if necessary.
Check All That Apply
Joint Venture Women Owned Small Business
Veteran Owned Business
Woman Owned Business
Joint Venture Economically Disadvantaged WOSM
Minority Owned Business
Community Development Corporation Owned Firm
By signing below, I represent that all information and attachments provided with this form is factual and correct. I
understand that misrepresentations, omissions of fact or incomplete information provided on this form may remove me
from further consideration.
Owner's Signature
Official Title
Print Name
Date
Submit this completed application in its entirely, along with the W9/NJS Form for Pre-Approval
using one of the following methods:
Email:
Apply On-Line: Fax: 856.324.9041
__ Pre Approved / __ Denied
Rev.10-16
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