Sample Independent Contractor Services Form
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INDEPENDENT CONTRACTOR SERVICES FORM
Name of Independent Contractor
Contractor (full name of person):
Address:
Citizenship Status:*
U.S. Citizen
Resident Alien
Nonresident Alien:
Visa/NAFTA status:
Country of citizenship:
Estimated Reimbursement
Project
Task
Award
Taxpayer Identification Number
(TIN/SSN):
$
Fee: $
Expenses: $
Total: $
Scheduled Dates of Performance
Name of country where services are to be
performed
Description of Services to be performed
Criteria for the classification of the person as an
independent contractor (attach separate sheet if
necessary)
Contractor Selection Criteria
____________________________________________
_________________________
Independent Contractor’s Signature
Date
CERTIFICATION OF THE PROJECT DIRECTOR
I certify that the work to be performed is essential to the project, that the services cannot be provided by any other
person receiving salary support under the grant, and that the rate is appropriate based on the qualifications of the
selectee and the nature of the work to be done.
__________________________________________ _____________________
Signature of the Project Director
Date
Approved: __________________________________________ _____________________
Date
(Operations Manager)
* Refer to reverse side of form for applicable definitions.
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Parent category: Business