Full Name (Legal Name - Must Match Driver's License) Phone Please leave this field empty. Email Address Driver's License State and Number Current Employer(s) and Current Position 3 Security Contracting References with Approval for Us Contact Them (company name, point of contact name and phone, your position and when) Previous Independant Contractor for L&A? (Yes/No) When? Security License(s) State, Number and Expiration (If none leave blank) Active/Retired LEO? Include Credential/Badge Number and Agency (If none leave blank) Agree to Duties, Term and Compensation (Yes/No) The Independent Contractor’s duties, term of engagement, compensation and provisions for payment thereof shall be as set forth in the estimate previously provided to LaSorsa & Associates by the Independent Contractor or which is otherwise provided by LaSorsa & Associates and mutually agreed to by the Independent Contractor. Equipment (Yes/No) The Independent Contractor agree's to provide at his or her own expense the required equipment for the agreed scope of work, which may include but not limited to: a smartphone with data plan, two-way radio, uniform items and conformity, a reliable means of transportation, a laptop computer, etc. Agree to Nondisclosure and Confidentiality (Yes/No) The Independent Contractor agrees that [he or she] will not disclose any of the trade secrets, inventions, innovations, processes, information, records and specifications owned or licensed by the Company, directly or indirectly, or use any of them in any manner, either during the term of this Agreement or at any time thereafter, except as required in the course of this engagement with LaSorsa & Associates. Please Upload Your Resume Please Upload Your W9 (Download Here: https://www.irs.gov/pub/irs-pdf/fw9.pdf ) Signature (must be legible and match name above) "My signature below confirms my agreement to the terms presented and to the temporary, 'at-will' independent contractor relationship between myself (the Independent Contractor) and LaSorsa & Associates; I am to receive payment 60 days post invoice upon project completion with approved expenses reimbursed; I must provide my own personal equipment; I have no claim to benefits such as sick or vacation pay or leave, worker’s compensation, health or disability benefits, unemployment insurance benefits, or employee benefits of any kind; I am subject to IRS Form 1099 and I must provide a W-9; I will indemnify and hold-harmless LaSorsa & Associates and its affiliates, officers, directors, employees, agents, successors and assigns from and against all losses, damages, liabilities, deficiencies, actions, judgments, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys' fees, arising out of or resulting from bodily injury, death or damage to real or tangible personal property resulting from acts or omissions as well as any breach of any representation, warranty or obligation under this Agreement; I accept the choice of law for an discrepancy, settlement or otherwise is Carteret County, NC."