First name

Last name

Home phone number

Work phone number

Mobile phone Number

Address

City

State

ZipCode

Email address

Mobile Phone Email address

What is your primary occupation?

Territory - able to cover in 50 mile area (list all cities)

Territory - willing to cover outside of 50 mile area (list all cities)

Are you performing any inspections now? If yes, what type? (check all that apply)

Pre Purchase Pre-Warranty Mechanical/Breakdown Off-Lease Claims Adjustment

Which inspection types are you interested in performing for CARCHEX? (check all that apply)

Pre Purchase Pre-Warranty Mechanical/Breakdown Off-Lease Claims Adjustment

Can you inspect: (check all that apply)

RV/Motorhome Motorcycle Boats/Marine ATV Large Trucks

Preferred number of inspections per week

(enter amount)

Maximum number of inspections per week

(enter amount)

Are you interested in performing services other than inspections (i.e. take photos & write descriptions of vehicles for sale)

Yes No

Do you have a computer with internet access?

Yes No

Do you regularly check your e-mail?

Yes No

Do you have a Digital Camera?

Yes No

Can you accept SMS (Text Messages) on your wireless phone?

Yes No

Do you have a Paint depth gauge?

Yes No

Do you have a Tread depth gauge?

Yes No

Do you have ASE CERTIFICATIONS?

Yes No

If Yes, please list ASE CERTIFICATIONS and how long for certified

Please list all other automotive CERTIFICATIONS(previous and current) and how long for certified

What are your current automotive QUALIFICATIONS?