Accounting
|
INDEPENDENT
CONTRACTOR QUALIFICATION ANALYSIS
(To
be completed and sent to Human Resources. Resubmit
every three (3) years) |
APPLICANT'S NAME
______________________________________________________________________________
Company of record:__________________________________________________________________________
(Individual's name or Company name that check will be
made payable to)
Company address:
City:
State:_____
Zip:_______
Telephone Number:
(_____ )
Fax Number: (
)
Puget Sound ESD
contact employee __________________________________________Extension
______________
  Services
being provided (check one box):
PRESENTER
CONSULTANT (attach draft agreement)
 
MENTOR
OTHER (attach draft agreement & describe below)
Description of
other services:_________________________________________________________________________
Please
answer ALL of the following eight questions by checking
the appropriate box:
 Yes
|
 No
|
•
I have been an employee of Puget Sound ESD?
If yes, dates of last employment_____________
|
 Yes
|
 No
|
•
I am or have been a member of the Washington State
Retirement System.
If yes, SOCIAL SECURITY NUMBER ____________________________
|
 Yes
|
 No
|
•
I maintain a place of business where I perform
and prepare most of the work necessary to execute
contracts for Puget Sound ESD. |
 Yes
|
 No
|
•
I hold myself out to the public as providing contractual
services to anyone desiring to purchase them.
If yes, list the names of a least two customers:
1._________________________________________
2._________________________________________ |
 Yes
|
 No
|
•
I advertise/promote my business. |
 Yes
|
 No
|
•
I am registered with the State of Washington or
other appropriate bodies to be engaged in business.
If yes, provide UBI# or EIN_______________________________________________
|
 Yes
|
 No
|
•
I understand that I am responsible for setting
my prices. Prices set below my costs may
result in a
loss which the ESD cannot be expected to cover.
|
 Yes
|
 No
|
•
I keep a separate set of books to account for
all revenues and expenditures. |
Potential contractor
certification/signature. I hereby
certify under penalty of perjury that the above is true
and accurate, and
I understand that this information will be used to evaluate
whether or not I will be able to perform work for Puget
Sound ESD as an
independent contractor or as a temporary employee.
I understand if there are any changes to the
above I will notify
Puget Sound ESD, Human Resources.
Signature__________________________________________________Date__________________________________
Human Resources
Office Use Only
Individual determined
to be: Temporary employee ___________ Contractor__________________
Human Resources
review ___________________________________ Date____________________
White: Business
Office
Yellow: Department Manager
Pink: Payroll
Form ICA1 07/03
|
