| Your Name |
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| Company Name |
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Street Address Line 1 |
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| Street Address Line 2 |
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| City |
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| State |
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| Zip Code |
-
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| Company Phone Number |
-
-
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| Company Fax Number |
-
-
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| Company Address Line 1 |
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| Company Address Line 2 |
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| City |
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| State |
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| Zip Code |
-
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| E-mail Address |
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| Cellualar Phone Number |
-
-
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| Pager Number |
-
-
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| Are You Insured? |
Yes
|
No
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| Are All Employees Insured? |
Yes
|
No
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| Name of Insurance Company |
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| Do you acknowledge and understand that if you are retained by Nationwide Home Services Inc., you will be working as an independent vendor; the completion of this application shall not be construed as creating an employee/employer/agency, partnership, or joint venture relationship between you or any of your agents and employees and Nationwide Home Services Inc., and/or affliates; that it is the intent of the parties that every vendor/contractor performing work for Nationwide Home Services Inc. be and remains an independent vendor/contractor and not employees of Nationwide Home Services Inc.; and that no vendor has the right to receive work from Nationwide Home Services Inc.; and that work shall be awarded based on performance which is determined on an individual basis? |
Yes
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No
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| Have you or your company ever been barred from completing HUD or Investor Agency work? |
Yes
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No
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| If "Yes", please explain |
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| Do you understand that if work is not completed according to guidelines Nationwide Home Services Inc., may charge you back for the additional cost(s) associated in completing the work? |
Yes
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No
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| Have you previously performed any work for Nationwide Home Services Inc.? |
Yes
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No
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| If "Yes", please explain |
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| Do you work directly for the mortgage servicing industry or our competitors? |
Yes
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No
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| If "Yes", who? |
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| Have you ever been convicted of a crime? |
Yes
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No
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| If "Yes", please explain |
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| Does Nationwide Home Services Inc. have your permission to request additional information to perform and hence perform a background check? |
Yes
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No
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| Do you know or were you referred by anyone who currently or in the past has worked for Nationwide Home Services Inc.? |
Yes
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No
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| Do you employ or utilize the services of any current/former Nationwide Home Services Inc. employee in your office or field work? |
Yes
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No
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| If "Yes", please list name(s) |
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| |
| Please review all entries and click "Submit" if done |
|
