Independent Contractor Check
Section 2.14
CONSULTANT/INDEPENDENT CONTRACTOR
DETERMINATION CHECKLIST
This form is used to determine that:
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the relationship between the consultant/independent contractor and that
__________________ Company is not that of employee/employer,
that the consultant/independent contractor is not related to an employee of
__________________ Company involved with the work,
and that the consultant/independent contractor is not a current ______________
Company employee.
Forward the completed form to __________________________ (Human Resources).
Section 1: To be completed by prospective consultant/independent contractor (i.e. service
provider)
Name of service provider:
___________________________________________________________________________
Contact person from service provider:
___________________________________________________________________________
Legal Personality of Service Provider:
Sole Proprietor  Close Corporation  Company (Pty) Ltd  Company Ltd 
Partnership  Charitable Organsisation or NGO 
Mailing Address:
___________________________________________________________________________
(street)
___________________________________________________________________________
(city)
___________________________________________________________________________
(state / province)
___________________________________________________________________________
(country)
___________________________________________________________________________
(postal code / zip)
_________________
________________________________________________
(code)
(telephone)
_________________
________________________________________________
(code)
(facsimile)
(email)
_________________________________________________________________
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Service No.1 of 1999
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Independent Contractor Check
Section 2.14
Taxpayer Identification Number:________________________________________________
Section 2: To be completed by service provider. Please answer all questions and sign in
space provided.
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Do you determine what means or methods to use in achieving the desired results?
_____yes _____no
Do you set your own priorities on time, effort, and hours of work?
_____yes _____no
Do you receive little or no training, supervision, or instruction from the
_______________ Company?
_____yes _____no
Do you provide similar services to other clients?
_____yes _____no
Do you engage in entrepreneurial activities in an established business at risk for loss?
_____yes _____no
Do you provide your own stationary, telephone, stenography service, business forms,
equipment, tools?
_____yes _____no
Do you have your own insurance for work-related injuries?
_____yes _____no
Are you a nonresident alien?
_____yes _____no
Are you currently employed by ________________ Company?
_____yes _____no
Do you have a relative employed at ________________ Company? If yes, list relative’s
name and dept.
_____ no _____ yes _______________________________________________________
I UNDERSTAND THAT AMOUNTS RECEIVED UNDER AN INDEPENDENT
CONTRACTOR/CONSULTANT AGREEMENT ARE SUBJECT TO ALL APPLICABLE
INCOME TAXES, AND THAT NO TAXES WILL BE WITHHELD FROM ANY
PAYMENTS DUE TO ME (EXCEPT FOR PAYMENTS TO NONRESIDENT ALIENS)
SINCE I AM NOT AN EMPLOYEE OF ___________________________ COMPANY.
UNDER PENALTY OF PERJURY, I CERTIFY THAT THE ABOVE INFORMATION IS
TRUE AND CORRECT.
_____________________________________________________
Signature of Proposed Service Provider/Date
Section 3: To be completed by the Department requesting the service. Human Resources
approval is required before a for services can be entered into between _______________
Company and the proposed service provider.
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Service No.1 of 1999
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Independent Contractor Check
Section 2.14
Specific service to be provided:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Department or College requesting the services:
___________________________________________________________________________
Departmental contact person: ______________________
Phone:
_______________________
Mail Code:
_______________________
Location where services will be provided:
___________________________________________________________________________
Start date:
Stop date:
Total fee:
_______________________
_______________________
R______________________ (excl. VAT)
Fee is based on :
fixed fee
hourly or daily rate
cost per unit
other(specify)
_______________________
_______________________
_______________________
_______________________
Does ________________ department pay travel expenses, lodging and/or meals?
__________no _____yes (specify) ______________________________________________
___________________________________________________________________________
_______________________________________________
APPROVED/DISAPPROVED by Human Resources.
Departmental Representative’s Signature/Date
_____________________________________________
HR Department representative/Date
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