Request for Information Concerning an Independent Contractor The purpose of this form is to request an independent contractor's responses to the CertifiedSE self-employment attestation and questionnaire. Please complete and submit the following form and a CertifiedSE team member will follow up with you. Provide the following information concerning the independent contractor who is the subject of your request.Independent contractor's name.* First Last Independent contractor's Employer Identification Number (EIN), if available.Provide the following information concerning, you, the requesting party.Business name.*Business address.* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of authorized person making the request.* First Last Position of authorized person making the request.*Identify your preferred method of communication.*TelephoneEmailContact telephone number*Contact email address* Enter Email Confirm Email Identify the reason for your request.*My business intends to engage the independent contractor.My business is conducting a preventative audit of its independent-contractor relationship with the individual.In the context of a dispute concerning the individual's status as an independent contractor.