Abt Associates Consultant Questionnaire

You are being considered for a proposed consultancy with Abt Associates. It is Abt Associates policy to confirm that individuals meet the qualifications for being an independent consultant. So that we are able to ascertain consultancy status, please complete and submit Part 1 of this Consultant Questionnaire. When asked for the “Abt Requestor”, indicate the Abt staff person who has requested your consultancy. Any questions/items denoted with an asterisk are mandatory.

In order to complete this Questionnaire, you will need to have the documents listed below available to attach.
IMPORTANT: Note that once you begin to fill out the Questionnaire, you will not be able to save this document or make changes to it later. When you are finished, click submit

Question 9:	If consulting for other organizations, provide documented evidence of work, such as a copy of an agreement/purchase order, a paid invoice, or any other type of document showing your engagement with the firm and the rate at which you were paid. Other than the rate at which you were paid, redacted copies of the documents are acceptable.
Question 11:	If you represent yourself as a consultant, sample of supporting materials (business cards, stationery, advertising, business phone, colleagues, etc.)
Question 16–19:	As an individual (person), you are a de facto small business, as defined by the Federal Acquisition Regulations (FAR) and referred to therein as a small business concern (FAR 19.001). As such, in order to attribute you to the correct small business socio-economic category (defined below), you represent and certify to one (or more) of these questions.
Question 20:	Resume (Required)
Question 21:	Biographical Data Sheet (USAID only)

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Contact Information

* Name
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* Address
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* Telephone
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Fax Number
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* E-Mail Address
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* Abt Associates Requestor Name
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* Abt Associates Requestor E-Mail
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* In which country will work be performed?
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* Are you a US citizen or have US tax obligations?

Yes
No

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* Do you currently receive a W-2 as an employee for any other company/organization?	Yes No
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* Do you file an IRS Schedule SE (Self-employment Tax) or Schedule C (Profit or Loss from a Business)?	Yes No
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* Are you certified by the SBA as a small disadvantaged business? (Explanation)	Yes No
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* Are you a woman (woman owned small business)? (Explanation)	Yes No
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* Are you a veteran of the U.S. Armed Services? (Explanation)	Yes No
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* Are you a service disabled veteran of the U.S. Armed Services? (Explanation)	Yes No
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If you are not a US citizen, please indicate your country of citizenship.
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Professional Information

* What is your profession?
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* Do you work as an independent contractor for any other entities?

Yes
No

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Documented evidence of such work must be provided, such as a copy of an agreement/purchase order, a paid invoice, or any other type of document showing your engagement with the firm and the rate at which you were paid. Other than the rate at which you were paid, redacted copies of the documents are acceptable.
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* Do you represent to the public that you are working for yourself as an independent contractor or independent consultant, on either a full-time or part-time basis?

Yes
No

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Please specify how (e.g, website, business cards, stationery, advertising, business phone, colleagues, etc.) and please attach sample of any supporting materials.
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* Do you have an incorporated business or partnership through which you conduct business?

Yes
No

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* Please list name of business or partnership
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* Please list EIN (not SSN)
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* Approximately what percentage of your business will the work you perform for Abt under this agreement constitute?	<10% <25% <50% <75% >75%
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* Are you a former Abt employee?

Yes
No

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* Was your date of termination within the last six months?	Yes No
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* Are you still receiving any sort of continued income from Abt (i.e. pension)?	Yes No
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* Do you have any other current engagements with Abt Associates?	Yes No
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Documents

* Resume
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Biodata Sheet (USAID only)
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Comments

Additional Comments
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By submitting this application, I certify that, to the best of my knowledge, the above information is accurate and complete.

Abt Associates Consultant Questionnaire - Version 1.2.0 - REV 85 [83e0729e9cbe]