Independent Contractor Bid Form 1 1. Submit a W-9 to us by U.S. mail (PO Box 2851, Orlando, FL 32802), or scan & email. 2. Begin with the form below, when completed continue to Form #2 and then Form #3. Full Name of Offeror: Email: Mailing Address: Phone: Any other business names used: EIN: Date of Birth: Place of Birth: Sex:MaleFemaleN/A Corporation Dates and places of established addresses(es):? (If actual places of addresses differ from the mailing address, furnish and identify both. Begin with present and go back for the past five years.) List beginning and end dates, address, city, state and zip code(s). Have you/your business carried or delivered mail in the last five years?YesNo If yes, please list: Education:? (List ALL education. Include highest level of education obtained of Independent Contractor submitting proposal.) Valid Driver’s License?YesNo License Number / State / Type:? If yes, include License Number, State of Issue, and Expiration Date. Is offeror a U.S. citizen? ?YesNo (If "yes" be prepared to should Form I-151 or I-551). Is offerror an alien with permanent resident status?YesNo Has the offeror EVER been convicted of, or Forfeited Collateral for any Felony/Misdemeanor Violation (except traffic violations)?YesNo During the last 10 YEARS has the Offeror ever Forfeited Collateral, been convicted, been imprisoned, been on probation, or been on parole for any violation of law?YesNo Has the Offeror EVER been convicted, or Forfeited Collateral for ANY assaults, firearms or explosives violations?YesNo Is the Offer (or you) NOW under charges for ANY violation of law?YesNo In the past five years, has the Offeror (you) been convicted of any traffic violations (other than parking) or currently have charges pending? (if yes complete below). Review this form carefully to ensure you have answered all questions fully and correctly. Failure to answer all questions may result contract denial and/or restriction of access to USPS mail areas by the USPS. I certify that the statement made by me in this questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I hereby authorize US Market Dynamics Group, Inc. (USMDG) to investigate my / my company's background and qualifications for purposes of evaluating whether I am qualified to be awarded a contract for which I am applying. I understand that USMDG may utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no information review will be done, and my application as an Independent Contractor will not be processed further. I understand that should a contractor offer be submitted by me / my company, that I am doing so as a potential Independent Contractor. Full Legal Name: Date Signed: