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 Dusk to Dawn Chaperones by you?
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 Dusk to Dawn Chaperones 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 Dusk to Dawn Chaperones by any of the schools, services, or employers listed on this application.
I also hereby release from liability Dusk to Dawn Chaperones and its representatives for seeking, gathering, and using such information to make decisions concerning my status as an independent contractor for Dusk to Dawn Chaperones 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 Dusk to Dawn Chaperones 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.
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