Short Form Independent Contractor Agreement
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SHORT FORM INDEPENDENT CONTRACTOR AGREEMENT
(For use when the total cost of services less than $5,000 and is made in a single payment)
This form should be sent electronically attached to the Online Payment Request
or faxed to 443-287-9357 (include the document number)
For new vendor setups, fax to 443-997-5322 along with a signed W-9 and New Vendor Form.
These forms are available at
PART I. DEPARTMENTAL CERTIFICATION - Department is to complete this section. Attach additional
es if necessary. Contractor and authorized officer sign PART II. TERMS AND CONDITIONS.
1. Name of Contractor:
SSN:
2. Address (Home address is required. If mailing address is different, please note.):
3. Describe the nature of service or scope of duties to be performed and how services will be provided.
4. Briefly describe the selection criteria used for this Contractor (e.g., education, training).
Yes
No
5. Do you contemplate continuing or recurring work with this Contractor?
Yes
No
6. Has the Contractor provided this or similar service to Department within the last 12 months?
7. Will a JHU employee determine the specific hours to be worked, the way services will be
Yes
No
performed, or otherwise supervise or direct the work of the Contractor?
If yes, please describe.
Yes
No
8. Will the services be performed at a JHU location?
Who will determine the hours the services will be performed?
JHU
Contractor
9. Will Contractor receive any training, guidance, or assistance, other than audio or
Yes
No
video presentation aids, or be provided with equipment, tools or supplies? If yes, please describe.
10. If assistance is needed to perform the services
Yes
No
ormed by a JHU employee or employees?
a.) will the assistance be perf
Yes
No
b.) will the Contractor hire his/her own help?
Yes
No
11. Is the recommended Contractor a current or former employee of JHU?
12. Is the Contractor related to any JHU employee who has controlling interest in or
Yes
No
relationship to the performance of these services?
ng these or similar services to
13. Is the Contractor actively engaged in providi
other organizations?
Yes
No
If yes, who are clients?
Yes
Yes
No
No
Visa Type:
14. U.S. Citizen
(For non-resident aliens only) IRS FORM 8233 attached?
15. Anticipated duration and costs of proposed professional services activity:
Dates or Period of Performance
/
/
12
through
/
/
12
Fee for Services: $
per
(lump sum, day, hour, etc.)
Total
$
Other expenses (hotel, travel, meals, etc.)
Total
$
Total fee for services and expenses (less than $5,000)
Total
$
0.00
Certified by Department Head or Designee_______________________________
Date
/
/
12
Alicia Haley, Fellowship Coordinator
Name and Title:
(Please Print)
Last updated on 10/16/2007
Page 1
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