ANL-482B (04-02)

**Personal Services Questionnaire Form B**

This questionnaire is to be completed by the individual providing
personal services or by incorporated individuals where **15 days or
greater of service is involved**. Please complete both pages of this
form and forward to your Procurement contact.

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Name of Individual Providing Personal Services

+---------------------------------------------------------+-----+------+
| 1\. Do you offer your services to the general public?   | *   | **   |
|                                                         | *Ye | No** |
| 2\. Are you doing business as an individual who is      | s** |      |
| incorporated?                                           |     |      |
|                                                         |     |      |
| 3\. Do you pay self-employment taxes, including FICA?   |     |      |
|                                                         |     |      |
| Please provide your Taxpayer's Identification Number    |     |      |
| (TIN)                                                   |     |      |
|                                                         |     |      |
| **[\_\_\_\_\_\_\_\_                                     |     |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}** |     |      |
|                                                         |     |      |
| If you do not have a TIN, please provide your Social    |     |      |
| Security Number:                                        |     |      |
|                                                         |     |      |
| **[\_\_\_\_\_\_\_\_                                     |     |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}** |     |      |
|                                                         |     |      |
| **[NOTE:]{.underline} One of the above numbers must be  |     |      |
| provided in order for us to make payment on this        |     |      |
| contract.**                                             |     |      |
|                                                         |     |      |
| 4\. Do you maintain an office staff?                    |     |      |
|                                                         |     |      |
| 5\. Are you listed in trade or professional directories |     |      |
| and/or do you advertise in newspapers, magazines, trade |     |      |
| journals, etc.?                                         |     |      |
|                                                         |     |      |
| 6\. Have you made a significant investment in           |     |      |
| facilities used in the performance of services for      |     |      |
| others?                                                 |     |      |
|                                                         |     |      |
| If "Yes," specify and give the amount of the investment |     |      |
| **[\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**              |     |      |
|                                                         |     |      |
| 7\. Will the services you provide be rendered           |     |      |
| personally?                                             |     |      |
|                                                         |     |      |
| 8\. Is it possible to suffer a loss as a result of      |     |      |
| services rendered?                                      |     |      |
|                                                         |     |      |
| If "Yes," how?                                          |     |      |
| **[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**    |     |      |
|                                                         |     |      |
| 9\. Will you perform the work on ANL premises?          |     |      |
|                                                         |     |      |
| 10\. Will you rely on ANL to furnish tools and          |     |      |
| materials?                                              |     |      |
|                                                         |     |      |
| 11\. Will you be working for others while under         |     |      |
| contract with ANL?                                      |     |      |
|                                                         |     |      |
| How many hours per week do you expect to work for ANL?  |     |      |
| **[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**    |     |      |
|                                                         |     |      |
| 12\. Have you previously worked or are you currently    |     |      |
| working for Argonne National Laboratory?                |     |      |
|                                                         |     |      |
|  As an employee                                        |     |      |
|                                                         |     |      |
|  Under a personal services contract                    |     |      |
|                                                         |     |      |
|  Under a consulting contract                           |     |      |
|                                                         |     |      |
|  As an employee of another organization                |     |      |
|                                                         |     |      |
| 13\. Are you a U.S. Citizen or Permanent Resident?      |     |      |
|                                                         |     |      |
| If not, are you authorized to work in the U.S.?         |     |      |
|                                                         |     |      |
| If you are a Non-Citizen -- Type of Visa held?          |     |      |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}          |     |      |
+---------------------------------------------------------+-----+------+

+-----------------------+--------+-------------+----------------------+
| > In accordance with  |        |             |                      |
| > the Immigration     |        |             |                      |
| > Reform and Control  |        |             |                      |
| > Act of 1986, please |        |             |                      |
| > provide documents   |        |             |                      |
| > that establish both |        |             |                      |
| > identity and        |        |             |                      |
| > employment          |        |             |                      |
| > eligibility.        |        |             |                      |
|                       |        |             |                      |
| **Acceptable          |        |             |                      |
| documents**           |        |             |                      |
|                       |        |             |                      |
| -   **Any ONE         |        |             |                      |
|     document from     |        |             |                      |
|     List A**          |        |             |                      |
|                       |        |             |                      |
|     **OR**            |        |             |                      |
|                       |        |             |                      |
| -   **Any TWO         |        |             |                      |
|     documents:**      |        |             |                      |
|                       |        |             |                      |
| > **ONE from List B   |        |             |                      |
| > AND ONE from List   |        |             |                      |
| > C**                 |        |             |                      |
+-----------------------+--------+-------------+----------------------+
| ***List A***          | *      |             | ***List C***         |
|                       | **List |             |                      |
|                       | B***   |             |                      |
+-----------------------+--------+-------------+----------------------+
| > *Documents that     | > *Doc |             | > *Documents that    |
| > Establish Both      | uments |             | > Establish          |
| > Identity and        | > that |             | > Employment         |
| > Employment          | > Est  |             | > Eligibility*       |
| > Eligibility*        | ablish |             |                      |
|                       | > Ide  |             |                      |
|                       | ntity* |             |                      |
+-----------------------+--------+-------------+----------------------+
|                       |        |             |                      |
+-----------------------+--------+-------------+----------------------+
| > 1\. U.S. Passport   | > 1\.  |             | > 1\. U.S. social    |
| > (unexpired or       | > Dr   |             | > security card      |
| > expired)            | iver's |             | > issued by the      |
| >                     | > l    |             | > Social Security    |
| > 2\. Certificate of  | icense |             | > Administration     |
| > U.S. Citizenship\   | > or   |             | > (other than a card |
| > (INS Form N-560 or  | > ID   |             | > stating it is not  |
| > N-561)              | > card |             | > valid for          |
| >                     | >      |             | > employment)        |
| > 3\. Certificate of  | issued |             | >                    |
| > Naturalization      | > by a |             | > 2\. Certification  |
| >                     | >      |             | > of Birth Abroad    |
| > (INS Form N-550 or  |  state |             | > issued by the      |
| > N-570)              | > or   |             | > Dept. of State\    |
| >                     | > ou   |             | > (Form FS-545 or    |
| > 4\. Unexpired       | tlying |             | > Form DS-1350)      |
| > foreign passport,\  | > poss |             | >                    |
| > with I-551 stamp or | ession |             | > 3\. Original or    |
| > attached\           | > of   |             | > certified copy of  |
| > INS Form I-94       | > the  |             | > a birth            |
| > indicating          | > U.S. |             | > certificate issued |
| > unexpired           | > pr   |             | > by a state,        |
| > employment          | ovided |             | > county, or         |
| > authorization       | > it   |             | > municipal          |
| >                     | > co   |             | > authority or       |
| > 5\. Alien           | ntains |             | > outlying           |
| > Registration        | > a    |             | > possession of the  |
| > Receipt Card with   | > phot |             | > U.S. bearing an    |
| > photograph (INS     | ograph |             | > official seal      |
| > Form I-151 or       | > or   |             | >                    |
| > I-551)              | >      |             | > 4\. Native         |
| >                     |  info. |             | > American tribal    |
| > 6\. Unexpired       | > such |             | > document           |
| > Temporary Resident  | > as   |             | >                    |
| > Card (INS Form      | >      |             | > 5\. U.S. Citizen   |
| > I-688)              |  name, |             | > ID Card\           |
| >                     | > date |             | > (INS Form I-197)   |
| > 7\. Unexpired       | > of   |             | >                    |
| > Employment          | >      |             | > 6\. ID Card for    |
| > Authorization Card\ | birth, |             | > use of Resident    |
| > (INS Form I-688A)   | > sex, |             | > Citizen in the     |
| >                     | > h    |             | > United States      |
| > 8\. Unexpired       | eight, |             | >                    |
| > Reentry Permit\     | > eye  |             | > 7\. Unexpired      |
| > (INS Form I-327)    | >      |             | > employment         |
| >                     | color, |             | > authorization      |
| > 9\. Unexpired       | > and  |             | > document issued by |
| > Refugee Travel      | > a    |             | > the INS (other     |
| > Document (INS Form  | ddress |             | > than those listed  |
| > I-571)              | >      |             | > under List A)      |
|                       | > 2\.  |             |                      |
| 10\. Unexpired        | > ID   |             |                      |
| Employment            | > card |             |                      |
| Authorization         | >      |             |                      |
| Document issued by    | issued |             |                      |
| INS which contains a  | > by   |             |                      |
| photograph (INS Form  | > fe   |             |                      |
| I-688B)               | deral, |             |                      |
|                       | >      |             |                      |
|                       |  state |             |                      |
|                       | > or   |             |                      |
|                       | >      |             |                      |
|                       |  local |             |                      |
|                       | > gove |             |                      |
|                       | rnment |             |                      |
|                       | > ag   |             |                      |
|                       | encies |             |                      |
|                       | > or   |             |                      |
|                       | > en   |             |                      |
|                       | tities |             |                      |
|                       | > pr   |             |                      |
|                       | ovided |             |                      |
|                       | > it   |             |                      |
|                       | > co   |             |                      |
|                       | ntains |             |                      |
|                       | > a    |             |                      |
|                       | > phot |             |                      |
|                       | ograph |             |                      |
|                       | > or   |             |                      |
|                       | >      |             |                      |
|                       |  info. |             |                      |
|                       | > such |             |                      |
|                       | > as   |             |                      |
|                       | >      |             |                      |
|                       |  name, |             |                      |
|                       | > date |             |                      |
|                       | > of   |             |                      |
|                       | >      |             |                      |
|                       | birth, |             |                      |
|                       | > sex, |             |                      |
|                       | > h    |             |                      |
|                       | eight, |             |                      |
|                       | > eye  |             |                      |
|                       | >      |             |                      |
|                       | color, |             |                      |
|                       | > and  |             |                      |
|                       | > a    |             |                      |
|                       | ddress |             |                      |
|                       | >      |             |                      |
|                       | > 3\.  |             |                      |
|                       | >      |             |                      |
|                       | School |             |                      |
|                       | > ID   |             |                      |
|                       | > card |             |                      |
|                       | > with |             |                      |
|                       | > a    |             |                      |
|                       | > phot |             |                      |
|                       | ograph |             |                      |
|                       | >      |             |                      |
|                       | > 4\.  |             |                      |
|                       | > V    |             |                      |
|                       | oter's |             |                      |
|                       | >      |             |                      |
|                       | regist |             |                      |
|                       | ration |             |                      |
|                       | > card |             |                      |
|                       | >      |             |                      |
|                       | > 5\.  |             |                      |
|                       | > U.S. |             |                      |
|                       | > Mi   |             |                      |
|                       | litary |             |                      |
|                       | > card |             |                      |
|                       | > or   |             |                      |
|                       | >      |             |                      |
|                       |  draft |             |                      |
|                       | >      |             |                      |
|                       | record |             |                      |
|                       | >      |             |                      |
|                       | > 6\.  |             |                      |
|                       | > Mi   |             |                      |
|                       | litary |             |                      |
|                       | >      |             |                      |
|                       |  depen |             |                      |
|                       | dent's |             |                      |
|                       | > ID   |             |                      |
|                       | > card |             |                      |
|                       | >      |             |                      |
|                       | > 7\.  |             |                      |
|                       | > U.S. |             |                      |
|                       | >      |             |                      |
|                       |  Coast |             |                      |
|                       | >      |             |                      |
|                       |  Guard |             |                      |
|                       | > Me   |             |                      |
|                       | rchant |             |                      |
|                       | > M    |             |                      |
|                       | ariner |             |                      |
|                       | > Card |             |                      |
|                       | >      |             |                      |
|                       | > 8\.  |             |                      |
|                       | >      |             |                      |
|                       | Native |             |                      |
|                       | > Am   |             |                      |
|                       | erican |             |                      |
|                       | >      |             |                      |
|                       | tribal |             |                      |
|                       | > do   |             |                      |
|                       | cument |             |                      |
|                       | >      |             |                      |
|                       | > 9\.  |             |                      |
|                       | > Dr   |             |                      |
|                       | iver's |             |                      |
|                       | > l    |             |                      |
|                       | icense |             |                      |
|                       | >      |             |                      |
|                       | issued |             |                      |
|                       | > by a |             |                      |
|                       | > Ca   |             |                      |
|                       | nadian |             |                      |
|                       | > gove |             |                      |
|                       | rnment |             |                      |
|                       | > aut  |             |                      |
|                       | hority |             |                      |
|                       | >      |             |                      |
|                       | > 10\. |             |                      |
|                       | >      |             |                      |
|                       | School |             |                      |
|                       | >      |             |                      |
|                       | record |             |                      |
|                       | > or   |             |                      |
|                       | >      |             |                      |
|                       | report |             |                      |
|                       | > card |             |                      |
|                       | >      |             |                      |
|                       | > 11\. |             |                      |
|                       | > C    |             |                      |
|                       | linic, |             |                      |
|                       | > d    |             |                      |
|                       | octor, |             |                      |
|                       | > or   |             |                      |
|                       | > ho   |             |                      |
|                       | spital |             |                      |
|                       | >      |             |                      |
|                       | record |             |                      |
|                       | >      |             |                      |
|                       | > 12\. |             |                      |
|                       | > Da   |             |                      |
|                       | y-care |             |                      |
|                       | > or   |             |                      |
|                       | > n    |             |                      |
|                       | ursery |             |                      |
|                       | >      |             |                      |
|                       | school |             |                      |
|                       | >      |             |                      |
|                       | record |             |                      |
+-----------------------+--------+-------------+----------------------+
| >                     |        |             |                      |
| **[NOTE]{.underline}: |        |             |                      |
| > Copies of           |        |             |                      |
| > acceptable          |        |             |                      |
| > documents must be   |        |             |                      |
| > provided in order   |        |             |                      |
| > for us to proceed   |        |             |                      |
| > with any further    |        |             |                      |
| > processing.**       |        |             |                      |
+-----------------------+--------+-------------+----------------------+
|                       |        |             |                      |
+-----------------------+--------+-------------+----------------------+
|                       |        | I           |                      |
|                       |        | ndividual's |                      |
|                       |        | Sig         |                      |
|                       |        | nature/Date |                      |
+-----------------------+--------+-------------+----------------------+