subject_line
Date
*
+
Company Name
*
EIN
*
Company Address
*
City
*
Zip Code
*
Work Site(if different from address)
City
Zip Code
Company Phone
*
Cell Phone
Email
*
Authorized Representative
*
Authorized Representative Title
*
Business Type / Industry
*
Current # of Employees
*
# Years in Business
*
Staffing Request
Please list job titles, compensation, responsibilities, # of positions looking to be filled, and timeframe:
Position
Salary / Pay Rate
General Duties
# of Workers
Expected Start Date
1
Position
Salary / Pay Rate
General Duties
# of Workers
Expected Start Date
2
Position
Salary / Pay Rate
General Duties
# of Workers
Expected Start Date
3
Position
Salary / Pay Rate
General Duties
# of Workers
Expected Start Date
Please identify any specific requirements for the position (s) listed above (i.e education, training, certification, physical capabilities):
*
Please identify any criminal history which excludes someone from eligibility for the position (s) listed above
*
No Guarantee of Worker Placement
No Guarantee of Worker performance quality
Not Responsible for Worker Conduct
No Guarantee of Worker Criminal Background History (aside from current charge for incarceration)
Print Name
*
Date
*
+
Signature
*
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