Please be advised that, while we are always accepting applications for independent contractors, we will only be communicating with those applicants where we have current demographic and geographic requirements (Canada Only).

Fields marked with a * are compulsory.

Personal Information
*First Name:	*Last Name:
*Gender: Male Female	*Date of Birth (YYYY/MM/DD):

Contact Information
Please specify the mailing address or the street address.
*Mailing Address:	*Street Address:
*City:	*Province: Ontario Quebec British Columbia Alberta Manitoba Nova Scotia Newfoundland Saskatchewan Prince Edward Island New Brunswick Yukon Territory Northwest Territory Nunavut
*Postal Code:
Major Intersection: for example: Yonge/King
Please specify at least one contact phone number.
*Phone: Home ()	Work () Extn.
Cellular/Mobile ()	Fax: Home ()
Fax: Work ()	*Email:

Employment Information
Occupation:	Current Employer:
Can we contact you at work? Yes  No
Are you or have you been an employee of a professional shopping company? Yes No
Are you or have you been an independent contractor (shopper/field representative)? Yes No

The following information helps us to determine what type of assignments you would be best suited for:
Do you speak any other languages fluently?	Yes No
If so, which?
Do you wear any corrective eyewear? Glasses Contact Lenses Neither
Provide a list of cities and towns in your immediate area in which you would be willing to complete assignments without receiving extra payment for travel. Please separate city names with a comma, For example: Toronto, Mississauga, Oakville
Provide a list of cities and towns in your immediate area in which you would be willing to complete assignments with extra payment for travel. (Keeping in mind that we do not pay for travel within major urban areas) Please separate city names with a comma, For example: Toronto, Mississauga, Oakville

References
This application will not be processed unless complete reference information is given.
*Professional Reference:
*Company Name:	*Contact Name:
*Street Address:	*City:

*State/Province:	*Postal Code:	*Phone Number:
AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNewfoundlandNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthwest TerritoryNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandYukon TerritoryNorthern Mariana IslandsGuamAmerican SamoaPalau

*Professional or Personal Reference:
Company Name:	*Contact Name:
*Street Address:	*City:

*State/Province:	*Postal Code:	*Phone Number:
AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNewfoundlandNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthwest TerritoryNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandYukon TerritoryNorthern Mariana IslandsGuamAmerican SamoaPalau

*In your own words, explain why would you be a valuable asset to our field representative group:

Thank you for your interest in our company.