W2 EMPLOYEE

NEW HIRE INFORMATION

Name(Required)

First Name Last Name Suffix

Phone(Required)

Work Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Start Date(Required)

Name of Recruiting Firm Submitting(Required)

Worksite Client(Required)

*If through VMS, please include the name of both the VMS and worksite Client. Ex: AnnLeo-ABC Assisted Living*

State Work Performed

Job Title(Required)

Regular Pay Rate(Required)

Overtime Pay Rate(Required)

Regular Bill Rate/Net Bill Rate(Required)

Overtime Bill Rate/Net Bill Rate(Required)

Special Instructions

Supervisor Name(Required)

First Name Last Name

Supervisor Phone Number(Required)

Supervisor Email(Required)

Alt. Supervisor Name

First Name Last Name

Alt. Supervisor Phone Number

Alt. Supervisor Email

Sales Split

Recruiter Split

Background/Drug Screen Ordering Options

Level 1 (SS Trace, 7 Year criminal check from residential history, National Reg Sex Offender) - $30 (may vary per state)

Drug Screening (10 panel) - $32.50 (may vary per state)

Other

Additional charges may apply depending on your county/state of residence

If other, please provide details(Required)

Include an attachment

Max. file size: 100 MB.

Submitted By *(Required)

First Name Last Name

Work Email(Required)

Submitted Date(Required)

A complete back office solution

From start to finish