MEMBER APPLICATION

Complete this online form or download and print your application and email the completed document to info@thepublicworks.me

Applicant Information

Full Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Social Security Number

Are you a citizen of the United States?

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever been convicted of a felony?

Yes

No

If yes, explain:

Company Information

Company Name

Federal ID #

Years in Business

Nature of Business

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Owner or Owners Name

Current or Previous Employment

Company

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Supervisor

Job Title

Dates Employed

Reason for Leaving

Trade References

Please list three professional/trade references:

Reference #1

Full Name

Position

Company

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference #2

Full Name

Position

Company

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference #3

Full Name

Position

Company

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Bank References

Please list 3 bank references:

Bank Reference #1

Insitution Name

Account Type

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account #

Phone 5

(###)

###

####

Bank Reference #2

Institution Name

Account Type

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account #

Phone

(###)

###

####

Bank Reference #3

Institution Name

Account Type

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account #

Phone

(###)

###

####