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<br /> <br />EXHIBIT “A” <br />Orange County Sportsplex <br />Independent Contractor Information Form <br /> <br />**** Please include a copy of Certificate of Insurance **** <br />**** Please include a completed W-9 form **** <br /> <br />Full Name: _________________________________________________________________________________ <br /> Last First M.I. <br />Address: _________________________________________________________________________________ <br />Street Address <br />__________________________________________________________________________ <br /> City State Zip Code <br />Primary Phone: __(______)______________________ Alternate Phone: __(______)______________________ <br />Email Address: ______________________________________________________________________________ <br />Social Security Number or Government ID: _______________________________________________________ <br />Birth Date: _________________________________________________________________________________ <br /> <br />Full Name: _________________________________________________________________________________ <br /> Last First M.I. <br />Address: _________________________________________________________________________________ <br />Street Address <br />__________________________________________________________________________ <br /> City State Zip Code <br /> <br />Primary Phone: __(______)______________________ Alternate Phone: __(______)______________________ <br />Relationship: _______________________________________________________________________________ <br /> <br />Title: _________________________________ Commission Rate: _____________________________________ <br />Start Date: _____________________________ Class/Clinic Rate: _____________________________________ <br />Supervisor: ________________________________ Department: _____________________________________ <br /> <br />Personal Information <br />Emergency Contact Information <br />Services Information <br />Docusign Envelope ID: 177AA06A-30B4-42FF-A85A-78B5A7C51DBE