Independent Contractor Form - University Of Alaska Fairbanks
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4Independent Contractor Status Determination Form
Except as noted in the following paragraph, this form is required to be completed for all contracts with
individuals for which treatment as an independent contractor is requested. The form is also required
for contracts with partnerships and other non-incorporated businesses for which the services to be
performed will be completed exclusively by a specific individual.
Completion is not required for contracts with entities such as corporations, governmental agencies,
professional organizations, or other colleges or universities which have provided the required
employer identification number. Nor is completion required for contracts with individuals engaged as
guest speakers or performers who provide one-time nonrecurring services and who are not otherwise
employed by the University.
Section A (To be completed by the prospective contractor):
1.
Name: ______________________________________________________________________
2.
Address: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3.
Type of business (sole proprietorship, partnership, etc.): _______________________________
4.
Social security or employer ID number: _____________________________________________
5.
Business License No.: Alaska ___________________ Other: __________________________
6.
Which business income and employer tax returns were filed for the prior year (Forms 1040 Sch.
C, Form 1065, Form 941, etc.)? __________________________________________________
7.
Number of years the business has been active? ______________________________________
8.
Do you maintain a business listing in the telephone directory or other publicly accessible
business directories? ___________________________________________________________
9.
Do you advertise or otherwise hold yourself out to the public to provide similar services (if yes,
describe how)? _______________________________________________________________
10.
Do you maintain your own shop or office? ___________________________________________
11.
Do you have a significant financial investment in your business (if yes, describe)? ___________
____________________________________________________________________________
____________________________________________________________________________
12.
Describe your primary business activities: ___________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Rev. 10-17-2011
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