1. Questionaire - GOE International, llc.

GOE 2114 PAGE 1 OF 4
GOE International, llc.
Mid-Atlantic - Mid-West & Gulf
PO Box 878, Newtown PA 18940 USA
Phone: 855.GOE.DIVE
INDIVIDUAL AND INDEPENDENT
CONTRACTOR QUESTIONNAIRE AND
AGREEMENT
________________________________________________
NAME OF INDIVIDUAL / CONTRACTOR
(Please Print Clearly)
Agreement Ref.: No. 2114
www.GOEdiving.com
Underwater and Marine Services
- ADCI Association of Diving Contractors International
Supporting: IMCA International Marine Contractors Association
Atlantic: Newtown, PA
Mid-West & Guf: Davenport, IA
Caribbean: St. Thomas, VI
Pacific: Monterey, CA
GOE 2114 PAGE 2 OF 4
GENERAL DATA:
NAME ______________________________________ CO. NAME _________________________________________________________
HOME PHONE
(
) ______________________________ CELL PHONE
(
) ______________________________
EMAIL: __________________________________________
CURRENT ADDRESS: _____________________________________________________________________________________________
SS NO.: ________________________________________ TAX ID NO.: ________________________________________
OTHER DATA:
DRIVERS LICENSE NO.
PASSPORT (Y/N)
STATE/COUNTRY ISSUED
NUMBER
EXP DATE
EXP DATE
PROFESSIONAL/MILITARY/COMMERCIAL DIVING TRAINING:
1. SCHOOL
CITY
STATE
FROM
TO
GRADUATE Y/N
2. SCHOOL
CITY
STATE
FROM
TO
GRADUATE Y/N
3. SCHOOL
CITY
STATE
FROM
TO
GRADUATE Y/N
MILITARY SERVICE:
BRANCH OF SERVICE
RANK AT SEPARATION
ACTIVE SERVICE FROM
TYPE
RESERVE SERVICE FROM
TO
TO
DUTIES PERFORMED
MILITARY SERVICE SCHOOLS ATTENDED
SUBJECTS STUDIED
LENGTH OF TIME IN EACH SCHOOL
_________________
ADDITIONAL INFORMATION
INDIVIDUAL / INDEPENDENT CONTRACTOR RATE(S):
INDIVIDUAL / INDEPENDENT CONTRACTOR 1099 RATE(S) MAY BE RECEIVED WEEKLY, MONTHLY, OR AT OTHER TIMES REFLECTING
GROSS AMOUNT FOR SERVICES RENDERED WITHOUT TAXES TAKEN OUT. ANY/ALL RATE(S) MAY BE ADJUSTED FROM TIME TO TIME AT
THE SOLE DISCRETION OF GOE INTERNATIONAL, LLC.
GOE 2114 PAGE 3 OF 4
SUBMISSION DOCUMENTS:
(REQUIRED TO BE SUBMITTED)
SEE QUESTIONAIRE SUBMISSION REQUIREMENTS
1. VALID DRIVERS LICENSE
2. COMMERCIAL DIVING ACDE ACCREDITED GRADUATE CERTIFICATION
3. ADDITIONAL REFERENCE LIST
4. RESUME / PREVIOUS PROJECT LIST FOR THE LAST 3 YEARS
5. MOST RECENT MEDICAL (FOR DIVING UNLESS NON-DIVING)
6. OTHER RELEVANT CERTIFICATIONS AND/OR QUALIFICATIONS
7. COMPLETED W9 FORM
PREVIOUS EXPERIENCE / PROJECTS: (FROM MOST RECENT)
1. COMPANY
CITY
STATE
FROM (YR)
TO (YR)
CITY
STATE
FROM (YR)
TO (YR)
CITY
STATE
FROM (YR)
TO (YR)
JOB DESCRIPTION
2. COMPANY
JOB DESCRIPTION
3. COMPANY
JOB DESCRIPTION
OTHER TRAINING
DESCRIBE:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
SPECIAL TALENTS / ABILITIES / CAPABILITIES:
LIST ANY SPECIAL ABILITIES OR CAPABILITIES
GOE 2114 PAGE 4 OF 4
WELCOME:
WELCOME TO GOE. AS AN INDIVIDUAL, CONTRACT INDIVIDUAL, INDEPENDENT, SUB, OR OTHER TYPE CONTRACTOR
YOU WILL INHERENTLY REFLECT ON US IN NUMEROUS WAYS INCLUDING YOUR APPEARANCE, HOW YOU PERFORM,
AND HOW YOU MAY INTERACT WITH OUR CUSTOMERS. YOU MUST BE PROFESSIONAL AT ALL TIMES AND RESPECTFUL
TO ALL GOE CUSTOMERS. YOU ARE NEVER REQUIRED TO WORK EXCLUSIVELY FOR GOE HOWEVER YOU MUST
COMPLETE ANY PROJECT YOU COMMIT TO AND/OR START WHICH MAY BE ACCOMPLISHED IN A VARIETY OF WAYS
CONSIDERING OUR REQUIREMENTS AND HOW PROJECTS MAY BE STRUCTURED, AWARDED, PLANNED, SCHEDULED,
AND MANAGED. WHEN EACH PROJECT IS COMPLETE WE HOPE YOU WILL JOIN US AGAIN FOR THE NEXT PROJECT IF
ASSIGNED. IT IS TO YOUR OR YOUR COMPANIES BENEFIT TO OBTAIN THE BROADEST RANGE OF EXPERIENCE WITH AS
MANY REPUTABLE COMPANIES AS POSSIBLE. ABOVE ALL ELSE COMES SAFETY AND WE ARE PROUD OF OUR PERFECT
SAFETY RECORD SINCE COMPANY INCEPTION. WE HAVE A VERY STRICT ZERO TOLERANCE DRUG POLICY FOR
OBVIOUS REASONS. THERE ARE MANY DISTINCTIONS BETWEEN GOE AND OTHER COMPANIES. BESIDES OUR
EXCEPTIONAL HIGH QUALITY WORK WE ARE ALWAYS GLAD TO OFFER ASSISTANCE WITH ACHIEVING YOUR GOALS
ANYTIME. WE HOPE YOU ENJOY EACH AND EVERY PROJECT.
GOE INTERNATIONAL, LLC. (''GOE'')
BY: RICHARD J. COPPOLA JR., MANAGER / MEMBER
BY: _______________________________________________
SIGNATURE
INDIVIDUAL / INDEPENDENT / OTHER CONTRACTOR
(''CONTRACTOR'')
NAME: ____________________________________________
PRINT NAME
DATE: __________ / __________ / ________________
IMPORTANT:
THE ABOVE INDIVIDUAL / INDEPENDENT OR OTHER CONTRACTOR
HAS, REPRESENTS, AND WARRANTS THAT ALL INFORMATION PROVIDED
IN THE HEREIN QUESTIONAIRE #2114 IS TRUE AND CORRECT AND THAT
THE INDIVIDUAL / INDEPENDENT / OTHER CONTRACTOR HAS READ,
ACKNOWLEDGES, UNDERSTANDS, AND AGREES TO THE QUESTIONAIRE AND
COORISPONDING AGREEMENT PROVISIONS, TERMS, AND CONDITIONS #2114
WITHOUT EXCEPTION ALSO LOCATED ON THE GOE WEBSITE.
Underwater and Marine Services
- ADCI Association of Diving Contractors International
Supporting: IMCA International Marine Contractors Association
Atlantic: Newtown, PA
Mid-West & Guf: Davenport, IA
Caribbean: St. Thomas, VI
Pacific: Monterey, CA

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