New Customer Summary We’re a team of staffing experts with a combined 90+ years of experience. And we love what we do. "*" indicates required fields General DetailsProspective Client Legal Entity Name* Prospective Client Website* Is this client associated with a VMS or MSP?*NoYesProspective Client Billing Address* Street Address Address Line 2 City select from dropdownAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Worksite Address* Street Address Address Line 2 City select from dropdownAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this role a remote position?*NoYesIs there another worksite to add?*NoYesWorksite Address (additional)* Street Address Address Line 2 City select from dropdownAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Nature of work (Be descriptive- i.e., manufacturing: build & repair small boats, no work done on water or in shipyard)*Job SpecificsHow Many Jobs Do You Have?* 1 2 Job 1 DetailsJob Title - Job 1* # of Temporary Workers Requested - Job 1* Estimated Payrate - Job 1* Estimated Bill Rate - Job 1* Contract Duration (Hours) - Job 1* Estimated Annual payroll (payrate x # hours x # weeks) - Job 1* Estimated Start Date - Job 1* Do you have a file for your Job Description? - Job 1*select from the dropdownNoYesUpload Job Description - Job 1*Accepted file types: doc, pdf, docx, docs, Max. file size: 128 MB.If you don't have file to upload, write out Job Description using this field. The job description should be descriptive or it can not be processed by underwriting. - Job 1*Has a job safety assessment been completed? - Job 1*NoYesJob Site Risks, Hazards & Exposures - Job 1*Is Personal Protective Equipment Required? (i.e PPE) - Job 1*NoYesDoes this client require a Certificate of Insurance? (COI) - Job 1*NoYesWhich screenings are requested by this client? - Job 1* Have you discussed passing on costs of pre-employment screening to your client? - Job 1*NoYesWhich pre-employment drug screen or OHS screenings are requested? - Job 1* Job 2 DetailsJob Title - Job 2* # of Temporary Workers Requested - Job 2* Estimated Payrate - Job 2* Estimated Bill Rate - Job 2* Contract Duration (Hours) - Job 2* Estimated Annual payroll (payrate x # hours x # weeks) - Job 2* Estimated Start Date - Job 2* Do you have a file for your Job Description? - Job 2*select from the dropdownNoYesUpload Job Description - Job 2*Accepted file types: doc, pdf, docx, docs, Max. file size: 128 MB.If you don't have file to upload, write out Job Description using this field. The job description should be descriptive or it can not be processed by underwriting. - Job 2*Has a job safety assessment been completed? - Job 2*NoYesJob Site Risks, Hazards & Exposures - Job 2*Is Personal Protective Equipment Required? (i.e PPE) - Job 2*NoYesDoes this client require a Certificate of Insurance? (COI) - Job 2*NoYesWhich screenings are requested by this client? - Job 2* Have you discussed passing on costs of pre-employment screening to your client? - Job 2*NoYesWhich pre-employment drug screen or OHS screenings are requested? - Job 2* Client Contract DetailsName* First Last Job Title* Email* Phone*Net Payment Terms* Do you know the Accounts Payable/Accounting Department contacts yet?*NoYesConversion/Buyout Schedule (ex. 1040 hour prorated buyout)* Conversion Placement Fee (ex. 25% of first year's annual salary)* Would you like to provide any additional notes about this client?*NoYesAdditional notes about Client* Important notes/details about client (i.e., requires vendor setup paperwork, PO#, etc.)* Form Completed By* First Last Authorized Partner Name* For an automated copy, please enter Email below (separate by semicolon if multiple emails)* NameThis field is for validation purposes and should be left unchanged. Facebook Follow Us Linkedin Find a Job