1. First Name:	*
Last Name:	*
2. Telephone Number:	*
3. Cell Phone Number:
4. Fax Number:
5. E-mail Address:	*
6. Address Line 1:
Address Line 2:
City:
State:
Zip:
7. Dates Affiliated with PSE&G and List All Titles You Held and Provide a Description of Your Duties and Responsibilities:
(1) to , Title/Duties:
(2) to , Title/Duties:
(3) to , Title/Duties:
(4) to , Title/Duties:
(5) to , Title/Duties:
8. Staffing Firms with Whom You Were/Are Affiliated with Applicable Dates:
(1)
(2)
(3)
(4)
(5)
9. What PSE&G Company Did You Perform Services For (you may select more than one):
Public Service Enterprise Group Incorporated
Public Service Electric & Gas
PSEG Power Connecticut LLC
Other:
10. Were You Required to Comply with Another Person's Instructions as to When, Where, and How to Work?
Yes   No Please Explain Your Answer:
11. Did PSE&G Provide You with Any Training?
Yes   No Please Explain Your Answer:
12. Were the Services You Performed Necessary to PSE&G and/or the PSE&G Unit Where You Were Working?
Yes   No Please Explain Your Answer:
13. Was It Necessary and/or Important for You to Perform Your Tasks for PSE&G Personally or Could You Delegate the Essential Components of the Task to Someone Else?
Yes   No Please Explain Your Answer:
14. Did PSE&G Hire Assistants to Work with You?
Yes   No Please Explain Your Answer:
15. Did You Work on PSE&G Projects Frequently, or Were You Performing the Tasks Infrequently?
Yes   No Please Explain Your Answer:
16. Did PSE&G Set Your Hours and Your Schedule?
Yes   No
17. Were You Working on PSE&G Projects Full-time, or Were You Working Other Jobs in Addition to the PSE&G Job?
Yes   No Please Explain Your Answer:
18. Did You Do the Work on PSE&G's Premises?
Yes   No Sometimes Please Explain Your Answer:
19. Did PSE&G Give You an Order or Sequence in Which the Tasks Had to Be Accomplished, or Were You Presented with a Job and Simply Told to Complete It without Any Direction as to the Individual Steps that Needed to be Taken to Accomplish the Job?
Yes   No Please Explain Your Answer:
20. Were You Required to Submit Reports to PSE&G?
Yes   No Sometimes Please Explain Your Answer: (Include the types of reports submitted and the frequency of the submission.)
21. Were You Paid on an Hourly, Weekly, or Monthly Basis, or Were You Paid When the Job was Finished?
Hourly   Salary   Weekly   Every 2 Weeks   Monthly Upon Project Completion
22. If You were Required to Travel, would PSE&G Reimburse You for Your Expenses?
Yes   No Not Applicable
23. Did PSE&G Provide You with Equipment to Use?
Yes   No Please Explain Your Answer: (Include what type of equipment and how often you utilized the equipment.)
24. Were You Required to Pay PSE&G Rent for the Time You Spent at Your Work Station?
Yes   No
25. If Your Project was Performed Successfully Would You Be Given a Share of the Profit Generated by the Successfully-Completed Task or Did You Ever Receive Any Bonuses from PSE&G?
Yes   No Please Explain Your Answer:
26. If Your Project Was Not Performed Successfully Would You Be Required to Share in the Loss?
Yes   No Please Explain Your Answer:
27. Were You Working for Businesses Other Than PSE&G?
Yes   No Please Explain Your Answer: (Identify the other businesses.)
28. Were the Services Which You Performed for PSE&G Available to the Public at Large?
Yes   No Please Explain Your Answer:
29. Did PSE&G Have the Right to Fire You?
Yes   No
30. Did You Have the Right to Refuse to Perform Services Assigned to You by PSE&G?
Yes   No
31. Do You Have Any Other Information Which You Feel Is Relevant to This Matter?
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