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 *FirstLastCompany NameYour company name, if applicable. Do not type Rodgers Security Solutions here.Employer Identification Number [EIN]The number provided must match the company name given above to avoid backup withholding.SSNOnly provide if you do not have an EIN. The number provided must match the 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.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? *YesNoGuard Card NumberIf applicable to the services you will provide to/through RSSGuard Card Expiration DateFirearm Permit NumberIf applicablePermit 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 PhoneFax NumberIf applicableEmail *Company Website / URLPhysical AddressAddress 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 NameFirstLastEmergency Contact PhoneAdditional InformationIRS Form W-9 To complete and submit to us a fillable W-9 Form please click the file link below. A new window will open to allow access and download: https://www.irs.gov/pub/irs-pdf/fw9.pdf File Upload Click or drag files to this area to upload. You can upload up to 5 files. You can upload your completed W-9 form, a copy of your business license or business liability insurance, or any other documentation here.Submit Contractor Forms Main Page
