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Quote Request Form
For all prospective new assignments, please complete and submit this form.
Date
*
MM slash DD slash YYYY
Completed By
*
First
Last
Your Email
*
Your Company Name
*
All prospective assignments must be approved by USA Staffing Services prior to any staffing. Please complete this form with as much detail as possible for all prospective assignments. If assignment is for a new customer, this QRF must be submitted to your Account Representative accompanied by a completed New Customer Summary. USA will endeavor to review all prospective assignments within 24 hours, however details of the requested assignment may arise that will extend the review process.
Customer Company Name
*
Customer/Billing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Worksite Address
*
Same as Billing
Different - See Below
Worksite Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
The overall scope of project or contract working on
*
Position Title and Job Description
*
Check All That Apply
*
Residential
Commercial
Industrial
Marine
Healthcare
Office Environment
Customer Predominate W/C Class Code (if known)
Estimated Number OF USA Staffing Services' Employees
*
Estimated Pay Rate
*
Estimated Bill Rate
*
Estimated Start Date
*
Estimated Weekly Hours
*
Estimated Contract Duration
*
Any unusual risks, tasks or potential hazard
*
Airborne Exposures
Respiratory Protection Required
Excessive Noise
Excessive Lifting (If yes answer below)
Other (If yes answer below)
None
Check all that apply
If Excessive Lifting - Weight in lbs?
If Other Checked Above - Explain
Any Personal Protective Equipment (PPE) Required
*
Safety Glasses
Gloves
Hardhat
Harness
Safety Boots
Earplugs
Other (If yes answer below)
None
Check all that apply
If Other Checked Above - Explain
*
Check all that apply
*
Working Above Ground Level (If yes, answer below)
Using Ladder higher than 6'
Using Scaffolding higher than 6'
Operating a Bucket/Boom/Scissor Truck
Working Below Ground Level (if yes, answer below)
Operation of Company Vehicles
Operation of Client Company Heavy Equipment
Client has Safety Program in place
Client has Mandatory Safety Orientations
If Working Above Ground Level - Height Above?
*
If Working Below Ground Level - describe
*
Notes:
