Dated: , 20___ Dated: , 20___ Solano Community College District By: By: Print Name: Print Name: Print Title: Print Title: Information regarding Consultant: License No.: _________________________: Employer Identification and/or Address: Social Security Number NOTE: Section 6041 of the Internal Telephone: Revenue Code (26 U.S.C. 6041) and Section 1.6041-1 of Title 26 of Facsimile: the Code of Federal Regulations (26 C.F.R. 1.6041-1) requires the E-Mail: recipients of $600.00 or more to furnish their taxpayer information Type of Business Entity: to the payer. In order to comply ____ Individual with these requirements, the ____ Sole Proprietorship District requires the Contractor to ____ Partnership furnish the information requested ____ Limited Partnership in this section. ____ Corporation, State: ______ ____ Limited Liability Company ____ Other: WORKERS’ COMPENSATION CERTIFICATION Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways: By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State. By securing from the Director of Industrial Relations a certificate of consent to self-insure, which may be given upon furnishing satisfactory proof to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Work of this Contract.
Dated: , 20___ Solano Community College District By: Print Name: Print Title: Dated: , 20___ By: Print Name: Print Title: Information regarding Consultant: License No.: Address: Telephone: Facsimile: E-Mail: Type of Business Entity: ____ Individual ____ Sole Proprietorship ____ Partnership ____ Limited Partnership ____ Corporation, State: ______ ____ Limited Liability Company ____ Other: _________________________: Employer Identification and/or Social Security Number NOTE: Section 6041 of the Internal Revenue Code (26 U.S.C. 6041) and Section 1.6041-1 of Title 26 of the Code of Federal Regulations (26 C.F.R. 1.6041-1) requires the recipients of $600.00 or more to furnish their taxpayer information to the payer. In order to comply with these requirements, the District requires the Contractor to furnish the information requested in this section. WORKERS’ COMPENSATION CERTIFICATION Labor Code Section 3700 in relevant part provides: Every employer except the State shall secure the payment of compensation in one or more of the following ways: By being insured against liability to pay compensation by one or more insurers duly authorized to write compensation insurance in this State. By securing from the Director of Industrial Relations a certificate of consent to self-insure, which may be given upon furnishing satisfactory proof to the Director of Industrial Relations of ability to self-insure and to pay any compensation that may become due to its employees. I am aware of the provisions of Section 3700 of the Labor Code which require every employer to be insured against liability for workers’ compensation or to undertake self-insurance in accordance with the provisions of that code, and I will comply with such provisions before commencing the performance of the Work of this Contract.
2014%200108%20Consultant%20Services%20Agreement%20(CEQA).docx