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.
Please list three professional references.
Disclaimer and Signature
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 Dewlyn LLC 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 Dewlyn LLC by any of the schools,
services, or employers listed on this application.
I also hereby release from liability Dewlyn LLC and its representatives for seeking, gathering, and using such
information to make decisions concerning my status as an independent contractor for Dewlyn LLC 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 Dewlyn LLC 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.
I certify that my answers are true and complete to the best of my knowledge.