Subcontractor Application

Applicant Name *

First

Last

Business Name *

Street Address *

City, State, Zip Code *

Phone Number *

Email Address *

Federal Tax ID Number (EIN) OR Social Security *

General Liability Insurance Company *

General Liability Policy Number *

General Liability Period Start Date *

General Liability Period End Date *

Does the company have or hire employees or subcontractors, other than the owner *

Workman's Compensation Insurance Company

If none, leave blank – If you do not carry Worker’s Compensation Insurance, you will be required to sign the Declaration of Independent Contractor Status, get it notarized, and return it to Molecular Coatings, Inc. Molecular can provide the necessary form.

Workman's Compensation Policy Number

If none, leave blank

Workman's Compensation Period Start Date

If none, leave blank

Workman's Compensation Period End Date

If none, leave blank