Staffing-Recruting Form

Company Name*

Company Street Address*

City*

State*--Please Choose--AL--AlabamaAK--AlaskaAZ--ArizonaAR--ArkansasCA--CaliforniaCO--ColoradoCT--ConnecticutDE--DelawareDC--Dist. of ColumbiaFL--FloridaGA--GeorgiaHI--HawaiiID--IdahoIL--IllinoisIN--IndianaIA--IowaKS--KansasKY--KentuckyLA--LouisianaME--MaineMD--MarylandMA--MassachusettsMI--MichiganMN--MinnesotaMS--MississippiMO--MissouriMT--MontanaNE--NebraskaNV--NevadaNH--New HampshireNJ--New JerseyNM--New MexicoNY--New YorkNC--North CarolinaND--North DakotaOH--OhioOK--OklahomaOR--OregonPA--PennsylvaniaRI--Rhode IslandSD--South DakotaSC--South CarolinaTN--TennesseeTX--TexasUT--UtahVT--VermontVI--Virgin IslandsVA--VirginiaWA--WashingtonWV--West VirginiaWI--WisconsinWY--Wyoming

Zipcode*

First Name*

Last Name*

Recruiting Niche *AdministrativeAccounting & FinanceContractsHRITPayrollOther

Perm Placement Fee Percentage (please include cap amounts if applicable) *

Temp-to-Perm Contract Duration (i.e. 3 months temp-to-perm, 4 months temp-to-perm, etc.)*

Phone*

Email*

Other Remarks