INDEPENDENT CONTRACTOR APPLICATION

 

 

 

 

 

JOHN CHARLES PROPERTIES, LLC.

 

828-260-0857

 

 

 

For Official Use Only

Date Received: _____________,  20__

 

Reviewed by: ___________________________________

 

Comments: _____________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

 

 

INDEPENDENT CONTRACTOR APPLICATION

 

 

Applications are considered for all independent contractors, and contractors are treated during the agreement, without regard to race, color, religion, sex, national origin, age, disability, or any other prohibited basis of discrimination as provided under applicable state and federal law.

 

 

Position(s) Applying For:  _____________________________

 

 

Background Information

 

Name

 

 

Telephone Number

 (         )        -

Street Address

 

 

Fax Number

 (         )        -

(City, State, Zip Code)

 

 

Email Address

 

Type of Entity (e.g., individual, corporation, partnership, etc.):

 

 

 

Description of Primary Business:

 

 

SIC (if business):

SSN (if individual):

EIN (if business):

 

 

Products/Services Offered (check all that apply):

 

 

  o   Consulting       o   Professional    o   Other      

 

 

 

 

 

 

 

 

 

Additional Information

 

 

Are you legally eligible for work in the U.S.A.?           o   Yes       o   No            (if yes, verification will be required)

 

Have you ever contracted with Company Name before?               o   Yes      o   No

If yes, when?                                                           

If yes, please attach previous contract to application.

 

Do you have [liability][malpractice] insurance?          o   Yes      o   No

 

If yes, please attach proof of insurance to application.

 

Do you agree to obtain any and all licenses that may be required to do business as an independent contractor or self-employed person?                                                                        

                                                                                       o   Yes      o   No

 

 

Do you understand that as an independent contractor, you would not be eligible for unemployment benefits at the end of any contract with Company Name?                 

                                                                                       o   Yes      o   No         

 

 

Do you understand that, as an independent contractor, you would be responsible for payment of any and all state and/or federal income, Social Security, self-employment taxes, sales and use taxes, unemployment taxes, and payroll taxes and you will receive a form 1099 for service provided to Company Name by you?

 

                                                                                       o   Yes      o   No

 

 

Contracting Request

 

Anticipated Rates:  $

Hours available (/week):

 

What is the earliest date you can begin work?

 

 

 

Previous Positions

*Please begin with most recent

 

 

Company:______________________________

 

Address: _______________________________

_________________________________________

 

Contact:  _____________________________

Telephone: (       ) ____ -_________

Dates of  Employment:   _________, ____

 

to

_________, ____

 

Pay or salary

 

Start:

 

 

Final:

Position:

Duties:

 

Reason for Leaving:

 

 

 

 

Company:______________________________

 

Address: _______________________________

_________________________________________

 

Contact:  _____________________________

Telephone: (       ) ____ -________

Dates of  Employment:   _________, ____

 

to

_________, ____

Pay or salary

 

Start:

 

 

Final:

Position:

Duties:

 

Reason for Leaving:

 

 

 

 

Company:______________________________

 

Address: _______________________________

_________________________________________

 

Contact:  _____________________________

Telephone: (       ) ____ -_________

Dates of  Employment:   _________, ____

 

to

_________, ____

 

Pay or salary

 

Start:

 

 

Final:

Position:

Duties:

 

Reason for Leaving:

 

 

 

Professional References

 

Name

 

Title

Contact Info

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Existing Contractual Relationships

*Please list all current independent contractor relationships

 

 

Company:______________________________

 

Address: _______________________________

_________________________________________

 

Contact:  _____________________________

Telephone: (       ) ____ -_________

Obligations:

Industry Type:

 

 

 

Monthly Hours Worked:

 

Effective Date:   _________, ____

 

End of Term:    _________, ____

 

 

 

Company:______________________________

 

Address: _______________________________

_________________________________________

 

Contact:  _____________________________

Telephone: (       ) ____ -_________

Obligations:

Industry Type:

 

 

 

Monthly Hours Worked:

 

Effective Date:   _________, ____

 

End of Term:    _________, ____

 

 

Company:______________________________

 

Address: _______________________________

_________________________________________

 

Contact:  _____________________________

Telephone: (       ) ____ -_________

Obligations:

Industry Type:

 

 

 

Monthly Hours Worked:

 

Effective Date:   _________, ____

 

End of Term:    _________, ____

 

 

 

 

Signature / Certification

I certify that the facts set forth in this application are true, complete, and correct to the best of my knowledge. I understand that any misrepresentations, falsifications, or omissions on this application can be grounds for immediate denial of my appointment or removal from consideration or, if I have entered into a contract with this company, for immediate termination of that contract. I authorize Company Name to make any necessary inquiries and investigations into my education, references, or employment history. I further authorize, unless otherwise indicated on this application, the release of my information to Company Name by any of the schools, services, or employers listed on this application.

 

I also hereby release from liability Company Name and its representatives for seeking, gathering, and using such information to make decisions concerning my status as an independent contractor for Company Name and all other persons or organizations for providing such information.

 

THIS IS NOT AN APPLICATION FOR EMPLOYMENT. I understand and agree that if this application is accepted, my status will be that of an independent contractor and as such, I will be solely responsible for all tax liabilities pertaining to monies received in the course of services I perform.

 

If I am retained by  Company Name  as an independent contractor I will:

• not be entitled to workers compensation benefits.

• not be entitled to unemployment insurance benefits unless unemployment coverage is provided by me or some other entity.

• be obligated to pay federal and state income tax on any moneys paid pursuant to the contract relationship.

• be required to provide professional and liability insurance.

 

I represent and warrant that I have read and fully understand the foregoing, and that I seek to become an independent contractor under these conditions.

 

 

Signature:

 

Date: