Fill and Sign the Self Employed Independent Contractor 497334741 Form

FOR COMPANY USE ONLY Based upon a review of this questionnaire and any other factors I have cited below, I have determined that this person (is) (is not) an independent contractor.                   Date             ______________________________________________________________________________________________ PART A: INDEPENDENT CONTRACTOR QUESTIONNAIRE TO BE COMPLETED BY PROPOSED CONTRACTOR Name of Contractor       SSN or Corporate Taxpayer ID No. of Contractor       Please answer questions “yes” or “no” whenever possible. When a more extensive explanation is required and there is no space on this form, please attach a separate sheet. The word “contract” refers to the agreement the Company is contemplating entering into with you. NOTE: IF YOU ARE A CORPORATION, YOU NEED NOT COMPLETE QUESTIONS 1-20 IF YOU RETURN THIS FORM, SHOWING ABOVE, YOUR CORPORATE FEDERAL TAXPAYER NUMBER AND ATTACHING A COPY OF YOUR CERTIFICATE OF CORPORATE GOOD STANDING ISSUED BY THE STATE OF { Insert State Name }. ALL POTENTIAL CONTRACTORS MUST ANSWER QUESTION 21 ON PAGE 3 AND VERIFY THAT THE SUPPLIED INFORMATION IS CORRECT BY SIGNING AND DATING THE LAST PAGE OF THIS DOCUMENT. Yes No 1. Have you performed services for the Company in any year(s) prior to 2004? If yes, please indicate which years. 2. Have you received any specific training, guidance, or direction from the Company as to how the Company expects the job (for which your services are contemplated) to be done? If yes, please describe what you are expecting (or have received) in the way of training or direction.       3. Will your services under the contract be performed on Company property? If no, please describe where the services are to be performed.             4. Do you expect to devote any full days (6 or more hours) or full weeks (30 or more hours) towards performing the services under the contract? If yes, please indicate approximately how many full days and/or full weeks you expect to devote during the life of the contract       Yes No 5. Are there any set or fixed hours or days of the week during which the Company is expecting you to perform services under the contract? If yes, please indicate the days and hours during which you will be performing services.       6. Please provide the date on which you expect to complete your services under the contract. 7. In order to perform services under the contract, do you intend to provide your own supplies or equipment? If yes, briefly describe the equipment/supplies. _____________________________________________________________________________ 8. If your response to No. 7 is yes, has the Company promised to or will you be expecting the Company to reimburse you in any way for the cost of the supplies or equipment? 9. Other than the above-referenced supplies and equipment, do you anticipate incurring any unreimbursable out-of-pocket expenses in the performance of the contract with the Company? If yes, please describe.       10. Do you have federal and state employer identification numbers? If so, please provide these numbers.       11. Within the past two years have you performed the same type services (as called for in the contract) for any client or customer other than the Company? If yes, please identify the client or customer and briefly describe the services performed.       12. Do you currently have clients or customers other than the Company for whom you are or will perform services during the duration of the contract? If yes, please identify client or customer by name and briefly describe the nature of services performed.       13. In the past two years have you notified any insurance company in conjunction with obtaining a business-related insurance policy that you are self-employed? If yes, please indicate the insurance company and the nature of the business-related policy.             14. Do you have your own employees to help you perform the services called for by your contract? (Do not refer to independent contractors you may use to assist you.)       15. Within the past two years have you been the employee of any employer (received a W- 2)? If yes, state the employer(s), the date(s) of employment, and the nature of the services performed.             Yes No 16. Do you have an office or business address other than your own home address? If yes, please state the address.             17. With regards to the following, please indicate whether you have: a. an existing business letterhead? (please attach) Yes No b. an existing business phone number other than your home number? (please indicate # ) c. filed for a fictitious business name? If yes, please attach a certified copy of the County issued certificate and an affidavit of publication. d. done public advertising for your business? If yes, please attach the ad copy or briefly describe your advertising efforts. 18. If you have answered parts or all of No. 17 with “Yes,” are the services represented in your answers the same type of services you will be performing for the Company? 19. Do you have a license from any governmental agency to perform the services under the contract? If yes, please state the type of license and name of the licensing agency.       20. Please describe the extent of any personal financial investment you have made in order to be self-employed. You may either choose to indicate the actual dollar amount of investment or, without disclosing any dollar amount, briefly describe any purchases, leases or other types of financial commitments made by you for self employment purposes.                         ALL POTENTIAL CONTRACTORS MUST ANSWER THE FOLLOWING QUESTION : 21. INDICATE WHETHER YOU OBJECT IF THE COMPANY DECIDES TO TREAT YOU AS A SHORT-TIME CONTRACT EMPLOYEE RATHER THAN AN INDEPENDENT CONTRACTOR. PLEASE STATE YES OR NO, AND IF YES, THE REASON FOR YOUR OBJECTION.                   I VERIFY THAT THE RESPONSES ABOVE ARE TRUE AND CORRECT. ________________________________________________________________________________ Contractor Date