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Indecendent Contractor Certification <br />The contractor is a firm or individual which: <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 />x Yes No <br />2. selects his clients and is free to work for one or more during any given interval; <br />x Yes No <br />3. determines the time and place the work will be performed; <br />x Yes No <br />4. provides the tools, materials and office space needed to perform the work; <br />x Yes No <br />5. agrees to perform specific services for a fixed price and does not receive regular <br />payments at stated intervals. <br />x Yes No <br />6. If the contractor is an individual, has he or she previously been an employee of the state? <br />Yes x No <br />If yes, give last date of employment. <br />Affirmative responses to items 1 through 5 indicate that the relationship is that of an independent <br />contractor. For any negative response submit a written ex~anation. <br />DOP-16 <br />