New Contractor Step 1 of 5 20% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone* Contractor FormsSigned Independent Contractor AgreementMax. file size: 30 MB.Signed W9 FormMax. file size: 30 MB.Copy of form at bottom of page.ADP Direct Deposit FormMax. file size: 30 MB.Copy of form at bottom of page.I-9 E-Verify: Will need copy of card(s) for I-9 E-Verify.Copy of Driver's License*Max. file size: 30 MB.Copy of Social Security CardMax. file size: 30 MB.Are you legally eligible for employment in this country?* Yes No Contractor RequirementsProof of Health InsuranceMax. file size: 30 MB.Proof of Auto InsuranceMax. file size: 30 MB.Professional LiabilityAttach copy of your Professional LiabilityMax. file size: 30 MB.Proof of LLCAttach copy of your LLC Certificate. If you need to establish your LLC use this link: https://inbiz.in.gov/start-business Max. file size: 30 MB. Health InformationAs a contractor, you are responsible to provide items below at your own expense. Are you able to perform the essential functions of the job with or without a reasonable accommodation?* Yes No PhysicalCopy of physical confirming that you are able to perform the essential functions of the job with or without restrictions, and free of communicable disease.Max. file size: 30 MB.Immunization RecordsCopy of Mantoux tuberculin skin test (required), Hepatitis vaccinations, Influenza shot. Please provide copies of any of these that you have.Max. file size: 30 MB.COVIDCopy of COVID Vaccination Card. Max. file size: 30 MB.COVID WaiverCopy of COVID waiver application and any supporting documentation. Max. file size: 30 MB.Drug ScreenCopy of 10-panel drug screen. Max. file size: 30 MB. CredentialsEducation*UniversityGraduation DateDegree CDR Number:CDR CardMax. file size: 30 MB.CredentialsCertification/License or Related CredentialsState if applicable State LicenseMax. file size: 30 MB.Attach resume Drop files here or Select files Max. file size: 30 MB. Attach business cardAs a contractor, please attach a copy of your business card. Drop files here or Select files Max. file size: 30 MB. Emergency ContactIn case of emergency at work please list your emergency contact person. Name First Last PhoneRelation to youDisclaimersI understand that I will be assigned a Nutrition Services secure email address and will be expected to run all communication with my facility through this email.* Yes No I understand that I will be given a Nutrition Services name tag and will be expected to wear the name tag while in the facility.* Yes No I agree to allow for a background check.* Yes No I understand that I must obtain a Dietitian Certification/License or hold a Certification/License in good standing for the state in which I will work.* Yes No The above information provided is true, correct and complete. As a contractor, any misstatements or omissions of fact may result in my cancellation of my contract.*Date* MM slash DD slash YYYY W9 Form Direct Deposit Form
