New Client Company Form

Recruiting Firm(Required)

Client Legal Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Payment Terms(Required)

A/P Name(Required)

First Last

A/P Phone Number(Required)

A/P Email Address(Required)

Purchase Order Number (if applicable)

Business Description(Required)

W.C. Class Code

State Work Performed(Required)

Start Date(Required)

Number of Placements(Required)

Length of Assignments(Required)

Pay Rate(Required)

Bill Rate(Required)

Position Description(Required)

Include an attachment

Max. file size: 100 MB.

Submitted By *(Required)

First Last

Email(Required)

Submitted Date(Required)

Comments

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