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City Wide Facility Solutions

Mt. Diablo  ·  Independent Contractor Application

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⚠️ Single-Use Form — Please Read Before Starting
This form cannot be saved and returned to later. Once you begin, you must complete and submit it in one session. Closing or refreshing this page will clear your progress.

Have all of the following files ready to upload before you start: W-9 form, government-issued ID, and your Certificate of Insurance (COI).

You will need two separate COIs — one for each of the entities below. Each COI must name that entity as an Additional Insured. They cannot be combined onto a single certificate.
COI #1 — Additional Insured:
City Wide Facility Solutions – Mt. Diablo
2001 Clayton Road, Suite 200
Concord, CA 94520
COI #2 — Additional Insured:
City Wide Franchise Company Enterprises, LLC
15230 W. 105th Terrace
Lenexa, Kansas 66219
Please provide both addresses to your insurance agent before completing this form so both COIs are ready to upload.
Thank you for your interest in partnering with City Wide Facility Solutions – Mt. Diablo.
Please complete all sections of this application. Required fields are marked with a *. Upload your supporting documents at the bottom. Once submitted, our team will review your application and be in touch shortly.

Questions? Contact us at dfawkes@gocitywide.com  |  Address: 2001 Clayton Road, Suite 200, Concord, CA 94520
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Business Information

2

Services Offered & Market Preferences

Services your company provides (select all that apply) *
Geographic Market Preferences
3

Pricing & Rates

4

Current Business Activity

Marketing Materials
Do you have marketing brochures?
Do you have business cards?
5

Personnel & Compliance

Employee Count
Compliance Checklist
Perform background checks on employees?
Pay state unemployment tax on all workers?
Follow all wage and labor laws?
Documented method of paying employees?
Collect I-9 forms for new employees?
Employees wear uniforms?
Supervisor checks employee work daily?
Policy to address at-risk client accounts?
6

Insurance

City Wide requires Workers' Compensation and General Liability insurance for all contractors. Your Certificate of Insurance must name City Wide as an additional insured (see upload section below).

Carry Workers' Compensation insurance?
Have General Liability insurance?
7

Equipment

Select all equipment your company currently utilizes
8

References

Janitorial Business Reference #1
Janitorial Business Reference #2
Business Credit Reference
9

Document Uploads

Please upload each document below. Accepted formats: PDF, JPG, PNG. Max 10 MB per file.

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W-9 Form *
IRS W-9 – Request for Taxpayer ID
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Government-Issued ID *
Driver's license or passport of the majority / primary owner
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COI #1 – City Wide Mt. Diablo *
Additional Insured: City Wide Facility Solutions – Mt. Diablo
2001 Clayton Rd, Suite 200, Concord, CA 94520
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COI #2 – City Wide Franchisor *
Additional Insured: City Wide Franchise Company Enterprises, LLC
15230 W. 105th Terrace, Lenexa, KS 66219
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Additional Document (Optional)
Marketing brochure, business license, or other
10

Acknowledgement & Signature

Independent Contractor Acknowledgement

I hereby acknowledge that I am a subcontractor of City Wide. As such, I am an owner of an independent business and am not an employee or agent of City Wide. I also acknowledge that as an Independent Contractor, I am free to employ other persons to perform services for my business, and that any persons so employed are solely my employees and are not the employees of City Wide.

I agree to comply with all federal, state, and local laws pertaining to the operation of my business. As an Independent Contractor, I acknowledge that I am solely responsible to maintain any licenses and insurance that may be required to operate my business, including automobile, liability, and workers' compensation insurance. I also acknowledge that I am solely responsible for any applicable taxes, including self-employment taxes, income taxes, social security, and payroll taxes.

I understand that no persons under the age of 18 will be allowed on any job site.
Authorized Signature *
Sign above using mouse or touch

By submitting this form you confirm all information is accurate. City Wide will contact you after reviewing your application.