Impanelment Application

US HQ: 18 North Main Street, Sherborn, MA 01770 || www.co-intel.com || Panel Questions: Email

* LAST NAME

* First Name

Middle Name

* Street (Physical) Address

* City

* County/Parish

* State

* Zip 5

* Zip 4

* Education

Property License Type

Complete License Number

Expiration Date

License State

Counties Covered

Experience

Masters/Ph.D. Program Name

College / University Name

Enrollment Verification Phone

* Work Phone:

* Cell Phone:

* Email Address:

*

I have paid subscriptions to:

* Home Computer

* Monitors

* Operating System

* Internet Connection

* Browser(s)

* I will be doing this work from:

my home

my own office

my employer's office

home, office and in between

*

In three or four sentences, please explain whether you prefer office work, field work or both, and why you think that evaluation piecework would be a good fit for your personal schedule, lifestyle or workstyle.

0/1000 characters

*

IMPORTANT!

Please CLICK HERE to open the PDF of our Confidentiality, Non-Compete and Assignment Agreement; if you accept the terms required for impanelment, please fill out the fields at the bottom of the PDF, save the form to your hard drive, then upload it in the space provided below. Thank you!

*

IMPORTANT!

Please download IRS W-9 form from by clicking HERE, fill out, sign with the words ELECTRONICALLY SIGNED BY [YOUR NAME], enter date, save and upload in the box below. IRS W-9 FORMS DO NOT REQUIRE "INK" OR GRAPHIC SIGNATURES. We keep these forms in a secure database, but if you're uncomfortable with filing electronically, just print and sign the completed form and mail to the address above (this will delay approval). WE CANNOT PAY YOU WITHOUT THIS COMPLETED FORM. If you have full PDF software and know how to apply a PDFK signature, please do so. Thank you!

Please upload a copy of your qualifications (CV, résumé) in the box below.

*

Finally, to prevent spamming and other types of Internet fraud, please enter the letters you see in the image, then click on Submit. You will hear from us by email within a day or two. NOTE: By completing and submitting this form, you are agreeing that all work assigned to you by CI would be conducted by you (not by your designee) as an independent contractor (1099 form) and NOT as an employee of Collateral Intelligence.

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