This is an example page. It’s different from a blog post because it will stay in one place and will show up in your site navigation (in most themes). Most people start with an About page that introduces them to potential site visitors. It might say something like this:

Hi there! I’m a bike messenger by day, aspiring actor by night, and this is my website. I live in Los Angeles, have a great dog named Jack, and I like piña coladas. (And gettin’ caught in the rain.)

  • Section A
  • Section B
  • Section C
  • Section D
  • Section E

Section A - Business Information

Please provide the legal name which appears on your business license, or under which your business will be operating as an independent contractor for GHP. Please further detail the contact information where you or your representative agent can be reached.

Full Business Name

Type of Identity (e.g., individual, corporation, LLC, , etc.) *

Business Mailing Address

Line 1

Line 2

City, State, Zip

Business Street Address

Line 1

Line 2

City, State, Zip

Business Contact Information

Business Phone Number

Business Fax Number

Business Email Address

Section B - Applicant Information

Please provide the full legal name and address for the individual who is applying to contract with GHP, and who will serve as the point of contact for GHP projects.​

First Name

Last Name

Date of Birth (yyyy-mm-dd)

Social Security Number

Title or Position

Residence Address

Line 1

Line 2

City, State, Zip

Applicant Contact Information

Phone Number

Alternate Phone Number

Applicant's Email Address

Section C - Contractor License Information

Please provide a detailed account of the highest class of license to contract that you or your business entity hold to do business in the Commonwealth of Virginia or Gloucester County, and the name and contact information for the qualifying individual(s) listed on that license. If you or your organization hold multiple licenses to contract, please list any additional, relevant licenses under “SECTION F – ADDITIONAL INFORMATION”

Classification of License

Issuing Entity

License Number

Date Issued/Renewed

Qualifying Individual

First and Last Name

Date of Birth (yyyy-mm-dd)

Social Security Number

Address Line 1

Address Line 2

City, State, Zip

Phone Number

Email Address

Section D - Insurance Information

Please provide the required information on any general liability insurance policies that you or your organization currently hold for the purposes of conducting business in the Commonwealth of Virginia and/or Gloucester County.

Name of Insurer

Type of Insurance/Coverage

Date Issued

Date Renewed

Amount of coverage (e.g., $1,000,000.00 in general liability) *

Insurer's Business Address

Line 1

Line 2

City, State, Zip

Insurance Representative

First and Last Name

Phone Number

Email Address

Section E - Required Application Questions

All questions in this section must be answered. Questions pertain to the applicant listed in Section B of this application form, and any and all employees of the business or applicant who are intended to work on the proposed contract for GHP. If “yes” in response to any question, the applicant must attach a separate sheet with a detailed explanation for each situation. ​ NOTE: Answering “yes” to any of these questions DOES NOT automatically disqualify you from bidding on GHP projects. These questions are required by GHP to meet due diligence standards and uphold the professional responsibilities of our organization.

To the best of your knowledge, is anyone listed on this application named in or responsible for any unsatisfied final judgements, liens, and/or claims against any bond or cash deposit pertaining to a construction project? If “yes” for this question, you are required to attach a statement identifying all judgements (pending or on record), liens, past due unpaid bills, claims, or suits and a detailed explanation of the situation. Include the names and addresses of the parties involved. If the obligation was or is being discharged in bankruptcy, attach a copy of the bankruptcy filing and a copy of the creditors list. *

Any unsatisfied final judgements

Has anyone listed on this application ever been convicted of or entered a plea of guilty or nolo contendere to any felony or misdemeanor involving moral turpitude (I.E., lying, cheating, or stealing) in the united states? Note: Convictions that were later expunged from the records of the court or set aside must be disclosed. However, some convictions should not be disclosed, including: - Convictions that were adjudicated in juvenile court; - Charges that were dismissed as a result of successful completion of a deferred entry of judgement program (diversion program). If “yes” for this question, you are required to attach a statement disclosing the nature of the conviction and explain the acts or circumstances that resulted in the plea/conviction(s). Note: Failure to report a disclosable plea/conviction may be grounds for the denial of your application. *

Felonies or misdemeanors

To the best of your knowledge, has anyone on this application ever received a citation from the Virginia department of professional and occupational regulation or had a contractor license or other professional or vocational license or registration denied, suspended, revoked, or otherwise disciplined by the commonwealth of Virginia or elsewhere (I.E., other U.S. State, U.S. Territory, Agency of the Federal Government, etc.)? For the purposes of this question, “disciplined” is an administrative action that resulted in a restriction or penalty being placed on any license you have or have possessed, such as a revocation, suspension, probation, or reprimand. If “yes” for this question, you are required to attach a statement detailing the events leading to this action. *

Citation

Direct supervision and control over construction operations, includes any one or a combination of the following activities: supervising construction, managing construction activities by making technical and administrative decisions, checking jobs for proper workmanship, or direct supervision on construction job sites. Will you, as the applicant, perform one or more of these duties. NOTE: This question must be answered by the applicant and/or qualifying individual listed on the contractor’s license. *

Supervision/Managing

Section F - Additional Information

Where the space available for answers to questions in SECTION A through SECTION E is insufficient for a full, detailed response, please list additional information in this section.

Additional Information

Section G - Certification of Accuracy

This section must be read by the applicant responsible for the contents of the GHP Independent Contractor Application. I certify, under the penalty of perjury under the laws of the Commonwealth of Virginia that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and correct, and that I have reviewed the entire contents of this application. I further recognize that, should any information in this application be incomplete or incorrect, GHP reserves the right to disqualify my business or organization from bidding on future contracts or projects.

Name of Individual Certifying the Application

Date of Certification (yyyy-mm-dd)

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