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<br />.'f <br /> <br />" <br /> <br />Independent Contractor Certification <br /> <br />The contractor is a fIrm or individual which: <br /> <br />1. is responsible for the results of the work to be undertaken, but is not subject to the state's <br />control as to the means and methods of accomplishing these results; <br />. . <br /> <br />x <br /> <br />Yes <br /> <br />No <br /> <br />2. selects his clients and is free to work for one or .more during any given interval; <br /> <br />x <br /> <br />Yes <br /> <br />No <br /> <br />3. determines the time. and place the work will be performed; <br /> <br />x <br /> <br />Yes <br /> <br />No <br /> <br />4. provides the tools. materials and office space needed to perform the work; <br /> <br />x <br /> <br />No <br /> <br />Yes <br /> <br />5. agrees to perform specifIc services for a fIxed price and does not receive regular <br />payments at stated intervals. <br /> <br />x <br /> <br />No <br /> <br />Yes <br /> <br />6. If the contractor is an individual, has he or she previously been an employee of the state? <br /> <br />If yes. give last date of employment. . <br /> <br />Yes <br /> <br />x <br /> <br />No <br /> <br />AffIrmative responses to it~ms 1 through 5 indiCate that the relationship is that of an independent <br />contractor., For any negative response submit a written explanation. <br /> <br />4 <br />