Staffing Services Request Request Staffing Services Step 1 of 2 50% Are you a new client?* Yes No How did you hear about us? Certified Payroll Yes No # of People NeededCompany Name Contact Person Order Placer PhoneFaxEmail Physical Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job DescriptionCompany Worker's Comp Code Start Date MM slash DD slash YYYY Hours Length of Assignment Short-Term Temporary Long-Term Temporary Temp-to-Hire Additional InformationSpecial Requirements "Safety First" Screening ProgramSome kind of description about this section can go here.Does your company require contract employees to attend any special safety orientations or training? Yes No Is Personal Protective Equipment (PPE) needed for our temporary employees, such as, hard hats, safety glasses, steel-toed shoes, gloves, etc.? Yes No If yes, what equipment is needed? Hard Hat Steel-toed Boots Work Boots Safety Glasses Back Brace Gloves Ear Plugs Other If "other" equipment is needed, please describe. Does your company conduct regular safety meetings? Yes No Could our temporary employees attend? Yes No Do you plan to have any our temporary employees operate equipment, such as, forklifts, trucks, backhoes, company car, etc.? Yes No If yes, what equipment will be operated? Will any of our temporary employees be working from elevations, such as, scaffolds, platforms, rooftops, ladders, etc.? Yes No If yes, what type of elevation? Will any of our temporary employees be working at an excavation site over four (4) feet in depth? Yes No Will any of our temporary employees be working within six (6) feet of the water's edge? Yes No Will any of our temporary employees be operating electrical/pneumatic tools? Yes No If yes, what type of tools? Will any of our temporary employees be doing any type of electrical work? Yes No If yes, what type of electrical work? Will any of our temporary employees be required to enter a confined space, such as, tanks, boilers, vats, pits, vessels, hulls of ships, or any enclosures with limited entrances and exits? Yes No If yes, what type of confined space? Will any of our temporary employees be required to lift over 25 pounds? Yes No If yes, what is the maximum weight that will be lifted? Will any of our temporary employees be exposed to asbestos, dust, silica, noise, flammables, combustibles, biohazards, carcinogens, or chemicals? Yes No If yes, what type of exposure will there be? Will any of our temporary employees be exposed to hazardous chemicals? Yes No If yes, would you like for our company to provide training? Please enter your name as your digital signature.* PhoneThis field is for validation purposes and should be left unchanged.