Consultant Questionnaire Form

Consultant Questionnaire Form

Client Name:    Consultant Name:

Recitals

WHEREAS, Client desires to engage Consultant to perform professional services as further described in this form and accompanying agreement sections; and Consultant represents that Consultant possesses the qualifications, skills, and experience necessary to perform such services in a professional manner.

WHEREAS, the parties intend to document the scope of services, payment terms, confidentiality obligations, and other material terms for the contemplated engagement, and to use this Questionnaire to supplement and inform the Scope of Work.

WHEREAS, this Questionnaire and the attached agreement provisions will be incorporated into and govern the consulting engagement effective as of Effective Date:

Consultant Contact & Business Information

Sole Proprietor    Limited Liability Company (LLC)    Corporation    Other:

Services, Experience & References

Insurance & Compliance

Does Consultant maintain professional liability insurance?  Yes No    If yes, Policy Limits:

Are there any regulatory or licensing requirements applicable to the services?  Yes No    If yes, describe:

Rates, Billing & Payment Terms

Standard Rate (hourly or project): $    Billing Schedule:

Invoices Due: Net days from invoice date.    Late Fee:

Payment Methods Accepted: Check ACH / Bank Transfer Credit Card Other:

Scope of Work

Term and Termination

Engagement Start Date:    Anticipated End Date:

Either party may terminate this engagement for convenience upon providing the required written notice. Termination for cause is permitted where a material breach is not cured within the notice period; Client will pay Consultant for services performed and reasonable expenses incurred through the effective date of termination.

Confidentiality

Consultant acknowledges that Consultant may receive Confidential Information in connection with this engagement. Consultant agrees to hold Confidential Information in strict confidence, to use it solely for performance of the Scope of Work, and not to disclose such information except as required by law or with Client's prior written consent. Confidential Information includes, but is not limited to, business plans, client lists, technical data, pricing, and proprietary methodologies.

Conflicts of Interest

Consultant certifies that Consultant has disclosed all known potential conflicts of interest. No known conflicts:

Governing Law; Entire Agreement

This Questionnaire, together with the incorporated terms and any executed statements of work, constitutes the entire agreement between Client and Consultant relating to the subject matter herein and supersedes all prior oral and written statements. This agreement will be governed by the laws of the state identified by Client's principal place of business, without regard to conflict of law principles.

Certifications & Acknowledgments

By checking the box below and executing this form, Consultant certifies that the information provided is true and accurate to the best of Consultant's knowledge and that Consultant agrees to the terms set forth in the Recitals, Scope of Work, Payment Terms, Term and Termination, Confidentiality, Governing Law, and Entire Agreement sections above.

I certify the foregoing.

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