Welcome To Capitalexpress

Home Courier Distribution Warehousing

PLEASE WATCH FOR OUR NEW WEBSITE COMING SEPTEMBER 15, 2008. THE CUSTOMER LOGIN WILL BE MORE CONVENIENT, APPEARING ON THE HOME PAGE

Our Coverage Area

Establish an Account

On-Line Order Entry

Medical Courier Services

Contractors Settlements

VENDOR APPLICATION

Date : Tuesday, January 6, 2009
Personal Information
Name :
Address :
City :
State :
Zip :
Phone :
Email Address :
Refered By :
Vehicle Information Please provide information for primary vehicle to be used in contracting your services.
Vehicle Make :
Model :
Year :
Insurance Co. :
Liability Limits on Your Policy :
Personal References Please list three people who have known you for at least one year.
Name :
Address :
Phone :

Name :
Address :
Phone :

Name :
Address :
Phone :

Have you been convicted of a felony within the last 7 years? : Yes No
If yes, please explain (will not necessarily exclude you from consideration) :
Military Service
Branch :
Dates of Service [mm/dd/yy] :	From To
Business Information
Business Name :
Corp :
Solo Prop :
Partnership :
Year Started :
SSN Or Tax ID :
Business References Please list your four most recent customers or employers.
Form :
To :
Name :
Address :
Contact :
Reason For Leaving :

Form :
To :
Name :
Address :
Contact :
Reason For Leaving :

Form :
To :
Name :
Address :
Contact :
Reason For Leaving :

Form :
To :
Name :
Address :
Contact :
Reason For Leaving :

AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

The Independent Contractor acknowledges and agrees that in the course of performing services for the customer the IC may come into contact with sensitive or proprietary information or products and acknowledges that release of said information or loss of product would cause irreparable harm to customer. Consequentially the IC agrees to allow a background check of IC.

I hereby authorize Capital Express, Inc. to make inquiries, either by written communication, by telephone, online, or in person to any present or former employer, creditor, credit bureau, government agency, educational institution, military establishment or any other persons or institutions knowledgeable of my background as to my prior history, work experience, nature of duties, work hours, wages, performance levels, reliability, responsibility honesty, and any other measures of my character or personality

In consideration for your developing such information, I specifically waive any confidential relationship of privacy position which may exist between us and completely release you from any responsibility or liability for damages which may occur as a result of the disclosure of this information

A photostatic, electronic, or any other copy of this instrument bearing my signature shall be equally legally valid as the original.

First Name :
Middle Name :
Last Name :
Date Of Birth [mm/dd/yy] :
Social Security Number :
Previous Names Used (to/from) :
Driver's Lic Number/State :
University - School/Yr Completed :
Email Address :
Please list all addresses where you have lived in the last 10 years
Current Street :
City :
State :
Date(FROM mm/yy - TO mm/yy) :

Current Street :
City :
State :
Date(FROM mm/yy - TO mm/yy) :

Current Street :
City :
State :
Date(FROM mm/yy - TO mm/yy) :

Current Street :
City :
State :
Date(FROM mm/yy - TO mm/yy) :

Current Street :
City :
State :
Date(FROM mm/yy - TO mm/yy) :