Form 68-0192 - Questionnaire For Determining Status Of Worker Page 5
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5Questionnaire for Determining Status of Worker
(Continued)
68-0192 (04-12)
For Service Providers or Salespersons
(continued)
Did the worker pay for a route or territory? ____Yes ____No
If “Yes”, who did the worker pay? _______________________________________________________________________
If “Yes”, how much did the worker pay? __________________________________________________________________
Does the firm furnish workers with any of the following?
a. Transportation
____Yes ____No
e. Samples
____Yes ____No
b. Drawing account ____Yes ____No
f. Business cards ____Yes ____No
c. Expense account ____Yes ____No
g. Order blanks
____Yes ____No
d. Office facilities
____Yes ____No
h. Price lists
____Yes ____No
Does the firm have the rights to require any of the following of the worker?
a. Attendance at meetings
___Yes ___No
h. Collection of accounts
___Yes ___No
b. Fixed hours of work
___Yes ___No
i. Resolution of customer complaints
___Yes ___No
c. A minimum number of calls
___Yes ___No
j. Other job duties in addition to selling
___Yes ___No
d. A minimum volume of sales
___Yes ___No
k. Maintenance of customer lists
___Yes ___No
e. Reports
___Yes ___No
l. Surety bond to be furnished
___Yes ___No
f. The firm's approval of sale
___Yes ___No
m. Policies to be followed
___Yes ___No
g. A minimum territory to be covered ___Yes ___No
n. Instructions to be followed
___Yes ___No
Does the worker maintain an inventory of merchandise? ____Yes ____No
If “Yes”, who owns the merchandise? ____Firm ____Worker ____Other (Specify) ______________________________
Where does the worker sell the product(s) or service(s)?
____Retail or wholesale establishment ____Worker's home
____Firm's location
____Customer's home ____Other (Specify) _____________________________
I have carefully examined all questions. My signature below certifies that my answers and statements are true and
complete to the best of my knowledge and belief.
Name:
Title:
Address:
City:
State:
Zip/Postal Code:
Phone:
Signature:
Date:
Page 5
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