Dewlyn Nonprofit Services

Independent Contractor Application


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.

Applicant Information


Date: July 1, 2022

Full Name:  

Address:

Phone:

Email:

Birth Date:

Date Avaiable:

Desired Compensation:

Applying for:

Are you a citizen of the United States: 

   If yes, are you authorized to work in the U.S?

Have you ever worked for this company?

   If yes, when?

Have you ever been convicted of a felony?

  If yes, explain:

 

References


Professional Reference 1:

Full Name:

Relationship:

Company:

Phone:

Address:

 

Professional Reference 2:

Full Name:

Relationship:

Company:

Phone:

Address:

 

Professional Reference 3:

Full Name:

Relationship:

Company:

Company:

Address:

 

 

Previous Employment


Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary: Ending Salary:

Responsibilities:

Start Date:   End Date:

Reason for leaving:

May we contact your previous supervisor for a reference:

 

Disclaimer and Signature


I understand that as an independent contractor, I will not be eligible for unemployment benefits at the end of any contract with Dewlyn LLC :

 

I understand that as an independent contractor, I 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 that I will receive a form 1099 for service provided to Dewlyn LLC by me:

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.

Leave this empty:

Signature arrow sign here

Signed by Cheryl Smith
Signed On: April 25, 2022


Signature Certificate
Document name: Independent Contractor Application
lock iconUnique Document ID: 3fe22b338264e5b6a6d5ca094245eb95376387e2
Timestamp Audit
April 13, 2022 7:13 am EDTIndependent Contractor Application Uploaded by Cheryl Smith - csmith@dewlyn.com IP 73.237.187.162