New Staffing Customer Information Sheet

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* PLEASE ATTACH CREDIT APPLICATION & STAFFING AGREEMENT, SUBMIT TO SALES ADMIN SUPPORT AND COPY YOUR PAYROLL ACCOUNT MANAGER.
New Staffing Customer Information Sheet
Customer Name: __________________________________________________________________________
Staffing Company Name: ___________________________________________ Branch Location: __________
Billing Contact Name: ______________________________________________________________________
Billing Address: ___________________________________________________________________________
_________________________________________________________________________
Billing Email: ______________________________________________________ Email Invoice:
Billing
Terms:
Net 30
Net 45
Other________________________________________
Physical Work Location Address: _____________________________________________________________
___________________________________________________________
Phone: ___________________________
Fax: ________________________________________________
What state will the employees be working in? __________________________________________________
Date employees become ESSG’s: ________________ 1st Pay Date: __________________________________
Projected Annual Payroll: ________________ Number of Placements: ______________________________
Pay Period:
(Sun-Sat)
(Mon-Sun)
Other: ______________________
Nature of Company’s Business: ______________________________________________________________
WC Code(s): _____________________________________________________________________________
Summary of Job Descriptions Involved: ________________________________________________________
Describe equipment/machinery to be operated: ________________________________________________
Is personal protection equipment required? If so, what? __________________________________________
Is there any exposure to chemicals? What kinds?________________________________________________
ESSG USE ONLY
Company/FEIN:
_______________ Sales Person:
_______________
WC Code:
_______________ Funded By:
_______________
Ins. Co:
_______________ Credit Amount:
_______________
WC Rate:
_______________ Credit Check:
_______________
Internal Rate:
_______________ Accounting:
_______________
Payroll Admin:
_______________ File/COI:
_______________
Branch/AMC Code:
_______________ Signed SA to client:
_______________
Updated:
___________________
rev. 0715

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