HomeContractor Information Go Back Contractor Intake FormThis form is used to provide contact information for all independent contractors and vendors that work with RSS. Please make sure you have all personal and business information required before beginning this form.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your Name *FirstLastYour Company Name [Not RSS]Your company name, if applicable. Do not type Rodgers Security Solutions here.Job Title If you have a job title at your company, please provide it here. If you do not have a company or title, please leave this blank. Will you or your company be providing security or executive protection services through Rodgers Security Solutions? *YesNoWhich of these forms of identification do you have? *State-issued Driver’s LicenseState-issued Identification CardPassportClick on all that apply. Please note that you will be asked to upload a copy of this form of identification at the end of this form.Guard Card NumberIf applicable to the services you will provide to/through RSS. Please know that we will verify this information.Guard Card Expiration DateFirearm Permit NumberIf applicable; please know we will verify this informationPermit Expiration DateList other permits and certificationsIf applicableAre you certified in First Aid, AED, and CPR?First AidCPRAEDAll of the aboveI’m not certifiedThis question applies to individuals and companies that are providing services to or through Rodgers Security Solutions where First Aid and CPR may be necessary.First Aid/CPR/AED Certification Expiration DateIf applicable for the role/services you will be providing through Rodgers Security SolutionsMobile PhoneMain Office PhoneIf you own a company that is providing services to/through RSSFax NumberIf applicableEmail *Company Website / URLOnly provide if you own a company that is providing services to/through RSSPhysical Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs the physical address and mailing address the same? *YesNoMailing AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs there a secondary business contact we should know about? *YesNoThis is for individuals that have business partners or associates that would make contact with Rodgers Security Solutions for billing or other reasons.SECONDARY CONTACT INFORMATIONPlease complete if there is a second person at your company that we can contact with questions. Only provide this information, if applicable.Secondary Contact NameFirstLastSecondary Contact Job Title at Contractor CompanySecondary Contact EmailSecondary Contact PhoneIs this person also your emergency contact?YesNoEMERGENCY CONTACT INFORMATIONPlease provide this information in case of emergency. Emergency Contact #1 Name FirstLastEmergency Contact # 1 PhoneEmergency Contact #2 NameFirstLastEmergency Contact #2 PhoneIf you don't have an emergency contact, please tell us how you want to proceed in case of emergency, and what information you want provided to emergency services personnel.Additional InformationWho Referred You to Rodgers Security Solutions?If you know the specific site(s) or event(s) you will be working at with RSS, please indicate hereTAX INFORMATIONSSN *Only provide if you do not have an EIN. The number provided must match the name given above to avoid backup withholding.Employer Identification Number [EIN]The number provided must match the company name given above to avoid backup withholding.Check the appropriate box for federal tax classification of the entity/individual whose name is entered above. Check only one of the following nine boxes. *Individual/sole proprietorC corporationS corporationPartnershipTrust/estateLLC- disregarded entityLLC- C corporationLLC- S corporationLLC- PartnershipNote: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.Under penalties of perjury, I certify that: *The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); andI am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (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 am no longer subject to backup withholding; andI am a U.S. citizen or other U.S. person (defined by IRS Form W-9); andThe FATCA code(s) entered on my IRS form W-9 (if any) indicating that I am exempt from FATCA reporting is correctCheck each box that you certify under penalties of perjury to be truthful and factual.FINANCIAL INFORMATIONHow would you prefer to be paid for your services? *Direct DepositACH PaymentZelleOtherWould you like to provide your payment information now? *YesNo, I want to wait until our work relationship is finalizedZelle InformationFinancial Institution NameRouting Number/ABA Account NumberType of accountCheckingSavingsBank AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeConfirm that you want 100% of your check deposited into this accountYesI hereby authorize Rodgers Security Solutions, Inc. to deposit my pay automatically to the account(s) indicated above and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error. This authorization will remain in effect until I cancel it in writing and in such time as to afford Rodgers Security Solutions, Inc. a reasonable opportunity to act on it. I also accept that a copy of this form is as valid as the original.YesCERTIFICATIONSI certify that I will address all concerns, complaints, questions, and suggestions to RSS management and not RSS's client(s), employees, or contractors. *YesI acknowledge that I will be working with individuals from diverse backgrounds, skill sets, and experience levels, including RSS employees, contractors, and clients. If a dispute or misunderstanding arises that cannot be amicably resolved, I will promptly seek assistance from RSS management. If my issue is with a site supervisor, I will seek assistance from RSS management. *YesI understand that RSS has a zero-tolerance policy for all forms of harassment and bullying. If I am accused of such behavior, I may be removed from my assignment and deemed ineligible for future assignments and contracts with RSS. I acknowledge that RSS reserves the right to take appropriate action based on its policies and any investigations, and I accept responsibility for my conduct in accordance with these standards. If I witness harassment or bullying involving an RSS employee, representative, or contractor, I will immediately notify RSS management. If I witness harassment or bullying involving an RSS client, I will follow the established safety protocols to address the situation. *YesI certify that I will return all materials, badges, equipment, uniforms, or property belonging to RSS and/or its clients at the end of my working relationship with RSS. Whether the relationship ends voluntarily or involuntarily, I will not retain any items that do not belong to me. *YesI certify that I have no conflicts of interest that would jeopardize my working relationship with Rodgers Security Solutions. *YesNoI Don’t KnowDo you have any outside employment, business interests, or affiliations that could potentially conflict with your duties at RSS? Do you or any immediate family members have a financial interest (e.g., ownership, investment, partnership) in any entity that does business with RSS?I certify that during my working relationship with Rodgers Security Solutions (RSS), I will not disclose any confidential information about RSS, its clients, employees, contractors, representatives, or agents, in any form (written, video, audio, or otherwise). If in doubt, I will treat information as confidential. I also understand that RSS will not disclose my confidential information for any purposes outside of our working relationship. This Agreement to maintain confidentiality of any disclosed information will remain in effect for ten (10) years. *YesToday's Date *UPLOAD YOUR SUPPORTING DOCUMENTS In the File Upload area below, please attach a copy of your driver’s license or identification card, guard card (if applicable), any permits and licenses, CPR/First Aid card, etc. FILE UPLOAD Click or drag files to this area to upload. You can upload up to 9 files. You can upload your completed W-9 form, a copy of your guard card, permits, or any other documentation here. That will save you and our team a lot of time. Submit
