Independence is Our Goal

Independent Contractor Application

Application Packet Checklist:

__ Application

__Two (2) References ___1. Professional ___ 2. Personal

__ Drivers’ License or State Identification Expiration Date: ___________________

__ Vehicle Insurance Card Expiration Date: ___________________

__ Vehicle registration Expiration Date: ___________________

__ Social Security

__ Affidavit of Good Moral Character

__ Copy of Current Certification

__ Contractor Agreement

__ Local Level Background Screen results Expiration Date: ___________________

__ FDLE/FBI Background Screen results Expiration Date: ___________________

__ Current First Aid Expiration Date: ___________________

__ Current CPR Card Expiration Date: ___________________

__ HIV/AIDS Blood-born Pathogen Certificate Expiration Date: ___________________

__ Domestic Violence Expiration Date: ___________________

__Assisting with Self-Medication Expiration Date: ___________________

__ Current Annual Physical Expiration Date: ___________________

__Work Permit/Alien Card/Voters’ registration Expiration Date: ___________________

__ Zero Tolerance Expiration Date: ___________________

__ Core Competency/Intro to Developmental Disabilities Expiration Date: ___________________

__ Health and Safety Expiration Date: ___________________

__ HIPAA Certificate Expiration Date: ___________________

Independence is Our Goal

Central Care Services, Inc

Application for Contract

NAME: _____________________________________________ DATE: ____________________________

LAST FIRST MIDDLE INITIAL

SOCIAL SECURITY#______-____-_______ DOB: ______/_______/_________

ADDRESS: _________________________________________________________________________

APT#: _________CITY: _________________________________STATE: _________ ZIP: ___________

HOME PHONE: _______________________________ CELL PHONE: ___________________________

POSTION DESIRED: _________________________________________ SALARY DESIRED: $___________

DATE YOU CAN START: ________________________ ARE YOU CURRENTLY EMPLOYED YES NO

EVER APPLIED TO THIS COMPANY BEFORE? YES NO WHEN? _______________________________

EDUCATION

GRAMMAR SCHOOL: _________________________________ DID YOU GRADUATE? YES NO

HIGH SCHOOL: ______________________________________ DID YOU GRADUATE? YES NO

COLLEGE: __________________________________________ DID YOU GRADUATE? YES NO

MAJOR: ____________________________________________

TRADE/ TECHNICAL SCHOOL: ___________________________________________________________

CERTIFICATION: _______________________________________________________________________

FORMER EMPLOYERS

MM/DD/YY TO MM/DD/YY COMPANY SALARY POSITION REASON FOR LEAVING

Independence is Our Goal

REFERENCES

NAME ADDRESS POSITION YEARS ACQUAINTED

*ATTACH A COPY OF ALL OF THE BELOW:

CPR: YES NO EXPIRATION DATE: ________________________________

HIV/AIDS BLOOD PATHOGEN: YES NO EXPIRATION DATE: ________________________________

DOMESTIC VIOLENCE: YES NO EXPIRATION DATE: ________________________________

MEDICATION ADMINSTRATION: YES NO EXPIRATION DATE: _____________________________

PHYSICAL: YES NO EXPIRATION DATE: ________________________________

DRIVERS’ LICENSE: YES NO DL# _________________________________EXPIRATION DATE: ______

Resume: _____ Yes _______ No

SIGNATURE ________________________________________ DATE: _____________________________

Independence is Our Goal

Central Care Services, Inc. Contractor Agreement

The Independent Contractor Agreement (this agreement) is entered into on this day _______ of (month)

___________________, ___________ (year) between Central Care services, Inc. (CCS), a Florida Corporation, and

__________________________________________, an independent Contractor (IC).

Whereas Central Care Services, Inc. provide services and utilizes qualified Independent Care Professionals including but not

limited to Certification of Nursing Assistants, Home Health Aides, Licensed Practical Nurses, Registered Nurses, Supported Living

Coaches, and Supported Employment Specialists to provide such services; and Whereas Central Care Services Inc., desires to

engage an IC to provide certain services to, or on behalf of Central Care Services, Inc. clients.

Engagement

The IC hereby agrees to provide services to Central Care Services, Inc. clients and perform all obligations as described in the job

description and qualifications and training requirement policy.

Term

The initial term of this agreement shall be one year commencing on ____________ (date). Upon the expiration of the initial

term, this agreement shall be automatically renewed for successive one-year terms unless otherwise terminated by CCS, of the

IC as provided herein.

Fees and Expenses

In consideration of this agreement CCS shall pay the independent Contractor a fee on a per diem basis. Therefore, no additional

expenses shall be reimbursed unless pre-approved by CCS in writing.

Employment Taxes

The parties acknowledge and agree that the IC shall be responsible for the collection and payment of any Federal, State, or

Local payroll tax in connection with any fees paid to IC pursuant to this agreement. IC agrees to indemnify and CCS harmless

from and against any and all liability, cost or expense incurred by CCS including reasonable attorney fees, in connection with

any income or employment taxes, penalty, interest, tax audit, re-determination, appeal or litigation arising out of any fees paid

by CCS to the IC in connection with this engagement.

Miscellaneous Provisions

This agreement contains the entire understanding and agreement of the parties hereto with respect to the matters set forth

herein. This agreement supersedes all prior or contemporaneous understanding, representations or agreements, written or

oral. This agreement may be executed in the counterparts. Facsimile or copied signatures shall be deemed originals.

In witness whereof, CCS and the IC have executed this agreement to be effective as of the date and year set forth above.

____________________________________ _________________________

Signature –Independent Contractor Printed Name

___________________________________ _________________________

Witness (CCS Representative) Printed Name

Independence is Our Goal

Certification of Good Physical and Mental Health

The state of Florida requires that all employees, working for a health care Agency to have this certificate completed by a

physician. A Physician examination must be within the past (12) months. The PPD and/or chest X-ray results must be with the

past 12 months.

This is to certify that _______________________________________________

Print Name

Was given a physical examination on __________________

Date

I find the above named patient to be in good physical and mental health; does not show evidence of communicable disease nor

any limitations in performing routine job duties.

PPD Chest: _____________________ Date________________________ Results____________________

Chest X-Ray: __________________________ Date___________________ Results___________________

Significant Findings:

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

___________________________________________ ________________________________

Physician Signature Date

Independence is Our Goal

Central Care Services, Inc. 2001 Palm Beach Lakes Blvd, Ste 300-D. West Palm Beach, Fl 33409

PH: 561-337-4338 Fax: 561-337-9025 E-MAIL: centralcareservices@yahoo.com

LETTER OF REFERENCE

______________________________________ has applied for a position with this company. Please fill

out the appropriate fields below and return to Central Care Services Inc. as soon as possible. An

additional, more detailed letter of references is desirable, but not mandatory. Thank you for your time.

Personal:

I have known the above named individual for ______________________ (months/years).

I know this person to be honest, reliable individual. ____Yes ____No

To the best of my knowledge, the above named individual does not engage in activities that violate the

laws of the State of Florida. ___True ___ False

The above named individual is suitable to work with individuals with developmental disabilities,

behavior difficulties, and seniors because:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I would: ____Recommend _____Not Recommend this individual for employment.

Signature: ________________________________________ Date: ______________________________

Independence is Our Goal

Central Care Services, Inc. 2001 Palm Beach Lakes Blvd, Ste 300-D. West Palm Beach, Fl 33409

PH: 561-337-4338 Fax: 561-337-9025 E-MAIL: centralcareservices@yahoo.com

LETTER OF REFERENCE

______________________________________ has applied for a position with this company. Please fill

out the appropriate fields below and return to Central Care Services Inc. as soon as possible. An

additional, more detailed letter of references is desirable, but not mandatory. Thank you for your time.

Professional:

I above named individual worked for this company for ___________ (months/years)

Their job title was: _________________________________________________________

In the workplace this person was a reliable individual. _____Yes _____No

We would rehire this individual. _____Yes _____No

The above named individual is suitable to work with individuals with developmental disabilities,

behavior difficulties, and seniors because:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I would: ____Recommend _____Not Recommend this individual for employment.

Please fill all relevant areas, this form will not be considered acceptable without the following

information:

Name: ________________________________ Contact number: ______________________

Position: _________________________ Company:___________________________

Address: ___________________________________City:__________________State:____Zip: ________

Signature: ________________________________________ Date: ______________________________

apJagency for persons with disabilities

State of Florida

State of Florida

AFFIDAVIT OF GOOD MORAL CHARACTER

County of

Before me this day personally appearedsays:

________________ who, being duly sworn,

I am an applicant for employment as a direct service provider or other individual screened pursuant to Chapter435, Florida Statutes, and Section 393.0655, Florida Statutes, or I am currently employed as a direct service

provider with:

By signing this form, I swear and affirm that I have not been found guilty of or entered a plea of guilty ornolo contendere (no contest) to, regardless of the adjudication, any of the following charges under theprovisions of the Florida Statutes or under any similar statute of another jurisdiction. I attest that I havenot been arrested for any of the following offenses and am currently awaiting disposition. I also attestthat I have not been adjudicated delinquent for any of the following offenses, regardless of whether therecords have been sealed or expunged.

I understand that I must acknowledge the existence of any criminal records relating to the following list ofoffenses. I understand that I am also obligated to notify my employer of any possible disqualifying offenses thatmay occur while employed in a position subject to background screening under Chapter 435, Florida Statutes. Ifurther understand that the list stated below is subject to change and may include offenses that were notpreviously included.

NOTE: The following list of offenses has been updated August 1, 2010, and includes offenses specificallyapplicable to direct service providers under Chapter 393, Florida Statutes.

Offenses Relating to:Sections: 393.0674 Felony offenses for the release or use of information from juvenile records of the Agency for

Persons with Disabilities for any purpose other than screening for employmentSexual misconduct with certain developmentally disabled clients or threats and/or coercion relatingto reports or testimony of sexual misconductSexual misconduct with certain mental Health patientsMedicaid provider fraudMedicaid fraudThe filing or disclosure of information from reports of adult abuse, neglect, or exploitation of agedpersons or disabled adultsCriminal acts that constitute domestic violence as defined in section 741.28, Florida StatutesMurderManslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravatedmanslaughter of a childVehicular homicideKilling of an unborn child by injury to the motherAssault, battery, and culpable negligence, if the offense was a felony.Assault, if the victim of offense was a minorBattery, if the victim of offense was a minorKidnappingFalse imprisonmentLuring or enticing a child for an unlawful purposeTaking, enticing, or removing a child beyond the state limits with criminal intent pending custodyproceedingsCarrying a child beyond the state lines with criminal intent to avoid producing a child at a custodyhearing or delivering the child to the designated person

393.135

394.4593

409.920409.9201415.111

741.30782.04782.07

Chapter:Sections:

782.071782.09784784.011784.03787.01787.02787.025787.04(2)

787.04(3)

APD 08/01/2010Page 1 of3

Chapter:Section:Chapter:Section:Sections:

Chapter:Sections:

Chapter:Section:Chapter:

790.115(1) Exhibiting firearms or weapons within 1,000 feet of a school790.115(2)(b) Possessing an electric weapon or device, destructive device, or other weapon on school property794.011794.041794.05796798.02800806.01810.02810.14810.145812817.034817.234817.505817.563817.568817.60817.61825.102825.1025825.103826.04827.03827.04827.05827.071831.01831.02831.07831.09843.01843.025

843.12843.13847874.05(1)893

Sections: 916.1075

APD 08/01/2010

944.35(3)944.40944.46944.47

985.701985.711

Sexual batteryFormer offenses for prohibited acts of persons in familial or custodial authorityUnlawful sexual activity with certain minorsProstitutionLewd and lascivious behaviorLewdness and indecent exposureArsonBurglaryVoyeurism, if the offense is a felonyVideo voyeurism, if the offense is a felonyFelony offenses for theft and/or robbery and related crimesFraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systemsFalse and fraudulent insurance claimsPatient brokeringFelony offenses for the fraudulent sale of controlled substancesCriminal use of personal identification informationObtaining a credit card through fraudulent meansFelony offenses for the fraudulent use of credit cardsAbuse, aggravated abuse, or neglect of an elderly person or disabled adultLewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adultFelony offenses for the exploitation of an elderly person or disabled adultIncestChild abuse, aggravated child abuse, or neglect of a childContributing to the delinquency or dependency of a childNegligent treatment of childrenSexual performance by a childForgeryUttering forged instrumentsForging bank bills, checks, drafts, or promissory notesUttering forged bank bills, checks, drafts, or promissory notesResisting arrest with violenceDepriving a law enforcement, correctional, or correctional probation officer means of protection orcommunicationAiding in an escapeAiding in the escape of juvenile inmates in correctional institutionObscene literatureEncouraging or recruiting another to join a criminal gangDrug abuse prevention and control if the offense was a felony or if any other person involved in theoffense was a minorSexual misconduct with certain forensic clients and reporting requirements for such sexualmisconductInflicting cruel or inhuman treatment on an inmate resulting in great bodily harmEscapeHarboring, concealing, or aiding an escaped prisonerIntroduction of contraband into a state correctional facilitySexual misconduct in juvenile justice programsContraband introduced into detention facilities

Page 2 of3

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED:

Signature of Affiant

Under the penalty of perjury, which is a first degree misdemeanor, punishable by a definite term of imprisonment,not exceeding one year and/or a fine not exceeding $1,000 pursuant to ss.837.012, or 775.082, or 775.083,Florida Statutes, I attest that I have read the foregoing, and I am eligible to meet the standards of good characterfor this caretaker position. This means that I have not been found guilty of or entered a plea of guilty or nolocontendere (no contest) to, regardless of adjudication, any of the offenses listed above or any similar statute ofanother jurisdiction. I attest that I have not been arrested for any of the above offenses and I am not currentlyawaiting disposition of any of the above offenses. I also attest that I have not been adjudicated delinquent for anyof the above offenses, regardless of whether those records have been sealed or expunged.

OR

Signature of Affiant

To the best of my knowledge and belief, my record may contain one or more of the foregoing disqualifying acts oroffenses.

OR

Signature of Affiant

I swear or affirm that I am a licensed physician, licensed nurse, or other professional licensed and regulated bythe Department of Health. I will be providing services that are within the scope of my licensed practice, and I amnot subject to the screening provisions of section 393.0655, Florida Statutes.

Sworn to and subscribed before me this day of _

My commission expires NOTARY PUBLIC, STATE OF FLORIDA

My signature, as a Notary Public, verifies the affiant's identification has been validated by

Page 3 of3AP D 08/0 1120 1 a

Form W-9 Request for Taxpayer Give Form to the(Rev. August 2013) Identification Number and Certification requester. Do notDepartment of the Treasury send to the IRS.Internal Revenue Service

Name (as shown on your income tax return)

N Business name/disregarded entity name, if different from above(J)

OJ<Il0.

Check appropriate box for federal tax classification: Exemptions (see instructions):c0 o Individual/sole proprietor o C Corporation o S Corporation tJ Partnership o Trust/estate

GI ~0.0 Exempt payee code (if any)~:;::; 0 Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ••.• 0 Exemption from FATCA reportingo 2.•...•.. code (if any)r: en.- r: 0'-- Other (see instructions) •n. 0

;;:::: Address (number, street, and apt. or suite no.) Requester's name and address (optional)'0II)Coen

City, state, and ZIP code(J)(J)

(f)

List account number(s) here (optional)m. Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line I Social security number I. ... .. . . . .to avoid backup withholding. For Individuals, this IS your social security number (SSN). However, for aresident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For otherentities, it is your employer identification number (EIN). If you do not have a number, see How to get aTIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose I Employer identification number Inumber to enter. DJJIDJJJl

~~----- -IDIII CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding, and

[]JJ -[[] -[JJJJ

3. I am a U.S. citizen or other U.S. person (defined below), and

4. The FATCA coders) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholdingbecause you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgageinterest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), andgenerally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See theinstructions on page 3.

Sign Signature ofHere u.s. person. Date.

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. The IRS has created a page on IRS.gov for informationabout Form W-9, at www.irs.gov/w9. Information about any future developmentsaffecting Form W-9 (such as legislation enacted after we release it) will be postedon that page.

Purpose of FormA person who is required to file an information return with the IRS must obtain yourcorrect taxpayer identification number (TIN) to report, for example, income paid toyou, payments made to you in settlement of payment card and third party networktransactions, real estate transactions, mortgage interest you paid, acquisition orabandonment of secured property, cancellation of debt, or contributions you madetoan IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), toprovide your correct TIN to the person requesting it (the requester) and, whenapplicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a numberto be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. Ifapplicable, you are also certifying that as a U.S. person, your allocable share ofany partnership income from a U.S. trade or business is not subject to the

withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you areexempt from the FATCA reporting, is correct.

Note. If you are a U.S. person and a requester gives you a form other than FormW-9 to request your TIN, you must use the requester's form if it is substantiallysimilar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S.person if you are:

• An individual who is a U.S. citizen or U.S. resident alien,

• A partnership, corporation, company. or association created or organized in theUnited States or under the laws of the United States,

• An estate (other than a foreign estate), or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business inthe United States are generally required to pay a withholding tax under section1446 on any foreign partners' share of effectively connected taxable income fromsuch business. Further, in certain cases where a Form W-9 has not been received,the rules under section 1446 require a partnership to presume that a partner is aforeign person, and pay the section 1446 withholding tax. Therefore, if you are aU.S. person that is a partner in a partnership conducting a trade or business in theUnited States, provide Form W-9 to the partnership to establish your U.S. statusand avoid section 1446 withholding on your share of partnership income.

Cat. No. 10231X Form W-9 (Rev. 8-2013)

Employment Eligibility VerificationDepartment of Homeland Security

U.S. Citizenship and Immigration Services

USCISForm 1-9

OMB No. \615-0047Expires 03/31/2016

~START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form.ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify whichdocument(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a futureexpiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1of Form 1-9no laterthan the first day of employment, but not before accepting a job offer.)

Last Name (FamilyName) First Name (GivenName) Middle Initial Other Names Used (if any)

Address (StreetNumberand Name) Apt. Number City or Town State Zip Code

Date of Birth (mmiddlyyyy) IU.~. Social ~ecuritYiN~mber E-mail Address Telephone Number

[[JJ-DJ-D~=OI am aware that federal law provides for imprisonment andlor fines for false statements or use of false documents inconnection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following):

D A citizen of the United States

D A noncitizen national of the United States (See instructions)

D A lawful permanent resident (Alien Registration Number/USCIS Number): _

D An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) . Some aliens may write "N/A" in this field.

(See instructions)

For aliens authorized to work, provide your Alien Registration NumberlUSC/S Number OR Form 1-94Admission Number:

1. Alien Registration Number/USCIS Number: _3-D Barcode

Do Not Write in This SpaceOR2. Form 1-94 Admission Number: _

If you obtained your admission number from CBP in connection with your arrival in the UnitedStates, include the following:

Foreign Passport Number: _

Country of Issuance: _

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

Signature of Employee: Date (mmlddlww):

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than theemployee.)

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge theinformation is true and correct.

Signature of Preparer or Translator: I Date (mm/dd/yyyv):

Last Name (FamilyName) First Name (GivenName)

Address (StreetNumberand Name) ICily or Town I State I Zip Code

Form 1-9 03/08/13 N Page 70f9

Section 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. Youmust physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed onthe "Lists ofAcceptable Documents" on the next page of this form. For each document you review, record the following information: document title,issldtng authority, document number, and expiration date, if anY.)ii

Employee Last Name, First Name and Middle Initial from Section 1:

List A ORIdentity and Employment Authorization

List BIdentity

AND List CEmployment Authorization

Document Title: Document Title: Document Title:

Issuing Authority: Issuing Authority: Issuing Authority:

Document Number: Document Number: Document Number:

Expiration Date (if any)(mm/ddlyyyy): 1# Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy):1*

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mm/ddlyyyy):

3-D BarcodeDocument Title: Do Not Write in This Space

Issuing Authority: $

Document Number:

Expiration Date (if any)(mm/ddlyyyy):

CertificationI attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) theabove-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge theemployee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy)' (See instructions for exemptions)

Signature of Employer or Authorized Representative I Date (mm/dd/yyyy) I Title of Employer or Authorized Representative

Last Name (Family Name) First Name (Given Name) IEmployer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) I City or Town I State IZiP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial IB. Date of Rehire (if applicable) (mm/dd/yyyy):

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employeepresented that establishes current employment authorization in the space provided below.

Document Title: I Document Number: IExpiration Date (if any)(mm/dd/yyyy):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and ifthe employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative: Date (mm/dd/yyyy): Print Name of Employer or Authorized Representative:

Form 1-9 03108/13 N Page 8 of9