Independent Contractor Information Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business Name (if applicable)

Business Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Tax Filing Status

Description of Services

Expected Start Date

Date

Hourly Rate ($)

Payment Terms

Preferred Payment Method

Bank TransferPayPalCheck

Contract Duration (in months)

Do you have a business license?

YesNo

Are you currently engaged with other clients?

YesNo

Do you have liability insurance?

YesNo

Policy Number

Policy Expiration Date

Date

Additional Notes or Comments

I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that providing false information may result in the termination of my contract.

Date

Signature

Independent Contractor Information Form

Insurance Information