INDEPENDENT CONTRACTOR APPLICATION

For Official Use Only

Date Received: _____________, 20__

Reviewed by: ___________________________________

Comments: _____________________________________
_______________________________________________
_______________________________________________
Wolflin Group _______________________________________________
_______________________________________________

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: Independent Agent________

Background Information
Name Telephone Number
( ) -

Street Address Fax Number

( ) -

(City, State, Zip Code) E-mail 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):

† Consulting † Professional † Other

Independent Contractor Application 1

 Additional Information

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

Have you ever contracted with Wolflin Group before? † Yes † No

If yes, when?
If yes, please attach previous contract to application.
Do you have [liability][malpractice] insurance? † Yes † 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?
† Yes † No

Do you understand that as an independent contractor, you would not be eligible for unemployment benefits at the end of any
contract with Wolflin Group?
† Yes † 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 Wolflin Group by you?

† Yes † No

Contracting Request
Anticipated Rates: 50% Commission Hours available (/week):

What is the earliest date you can begin work?

Previous Positions
*Please begin with most recent
Dates of Pay or salary Position: Reason for
Company:______________________________ Employment: Duties: Leaving:
_________, Start:
Address: _______________________________ ____
______________________________________
to Final:
Contact: _____________________________ _________,
Telephone: ( ) ____ -_________ ____

Dates of Pay or salary Position: Reason for

Company:______________________________ Employment: Duties: Leaving:
_________, Start:
Address: _______________________________ ____
______________________________________
to Final:
Contact: _____________________________ _________,
Telephone: ( ) ____ -________ ____

Independent Contractor Application 2

 Dates of Pay or salary Position: Reason for
Company:______________________________ Employment: Duties: Leaving:
_________, Start:
Address: _______________________________ ____
______________________________________
to Final:
Contact: _____________________________ _________,
Telephone: ( ) ____ -_________ ____

Professional References
Name Title Contact Info

Existing Contractual Relationships

*Please list all current independent contractor relationships
Obligations: Industry Type:
Company:______________________________

Address:
_______________________________ Monthly Hours Worked:
Effective Date: _________, ____
______________________________________
End of Term: _________, ____
Contact: _____________________________
Telephone: ( ) ____ -_________
Obligations: Industry Type:
Company:______________________________

Address:
_______________________________ Monthly Hours Worked:
______________________________________ Effective Date: _________, ____

Contact: _____________________________ End of Term: _________, ____

Telephone: ( ) ____ -_________

Company:______________________________ Obligations: Industry Type:

Address:
_______________________________
______________________________________ Effective Date: _________, ____ Monthly Hours Worked:

Contact: _____________________________ End of Term: _________, ____

Telephone: ( ) ____ -_________

Independent Contractor Application 3

 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 Wolflin Group 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 Wolflin Group by any of the schools, services, or employers listed on this
application.

I also hereby release from liability Wolflin Group and its representatives for seeking, gathering, and using such information to make decisions
concerning my status as an independent contractor for Wolflin Group 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 Wolflin Group 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:

Independent Contractor Application 4