Company Name*

Customer ID*

Company Address*

Street Address Address Line 2 City State ZIP Code

Company Phone Number*

Company Website

If you don't have a website leave it empty.

Bill Rate*

# of Talent*

Weekly Hours Per Associate*

Payment Terms*

Origin Date*

Category*

Account Type*

Is this a Payroll Account?*

Account Manager*

Branch*

Branch Manager Name*

Physical Work Location Addresses*

List specific tasks talent will be performing at the jobsite*

Job Titles to be Staffed (Be more specific than “General Warehouse”)*

Have you physically gone to the client site and toured the work areas? (If yes, please submit the Site Safety Evaluation to [email protected])*

Is this location manufacturing, distribution or other?*

Question/Comment*

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