Contractor Service Request Form

Contract Company Name

Southern Company Affiliate

Date

Project Manager Email

Project Manager

contractor's primary contact at Southern Company

Project Manager Phone

Does this Contract Worker require NERC/CIP access?

Yes

Worker Classification

Will this worker drive on public roads on behalf of Southern Company?

Yes

Following the requirements outlined in your contract with Southern Company, select screenings required below. Screen(s) Required

Reason for Screens

Special directions

This information should be the individual at your company who is authorized to receive your employer status and is authorized to place orders.

Contractor Company Contact First Name

Contractor Company Contact Last Name

Contractor Company Contact Title

Contractor Company Contact Email:

Contractor Company Contact Phone

Contract Company Contact Fax

Contractor Company Contact Tax ID

Contract Worker to be screened

(please use worker’s legal first and last name):

Contract Worker to be screened email

Additional contract workers to be screened

(one contract worker and email per line)