Business Name: Current Address: City: State: ZIP Code: Year Established: Insured: Yes No Bonded: Yes No Phone: Fax: Email: Are you anIndependent Contractor? Yes No (If No, please skip this section) Employer Name: City: State: ZIP Code: Employee Name: Employee Email: Experience: Years: Months: Shirt Size: M L XL XXL What percentage of your business is focused in the following areas: Home Installation: % Coin Amusement: % Billiard Room: % I, the above mentioned applicant, acknowledge that all information released to Championship, LLC is accurate and may be verified with my Employer upon request. Name: Address: City: State: ZIP Code: Position: Years Experience:
