Full Name

Phone Number

Email Address

Date of Birth

Address

City, State

Zipcode

Do you have a valid driver's license? Do you have a valid driver's license? Yes No

Driver's License Number

State of Issue State of IssueAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VerginiaWisconsinWyoming

Vehicle Make & Model

Vehicle Year

License Plate Number

License Plate Number Expiration

Vehicle Insurance Provider

Insurance Policy Number

Are you currently delivering for other platforms? Are you currently delivering for other platforms? Yes No

If yes, which one(s)?

Do you have a smartphone with data access? Do you have a smartphone with data access? Yes No

What areas are you willing to deliver in? What areas are you willing to deliver in? Las Vegas Detroit Atlanta Miami Los Angeles Chicago Other

If 'Other' was selected, please add it here

What times are you available to deliver? What times are you available to deliver? Morning (8AM - 12PM) Afternoon (12PM - 5PM) Evening (5PM - 10PM) Late Night (10PM - 2AM)

Electronic Signature

Date