Professional Employer Organization - Affidavit of Temporary Help Service Agency

Temporary Help Service Agency Information:
Tell us more about your
Temporary Help Service Agency:
Name of
Temporary Help Service Agency
   
Please enter the full name of the Temporary Help Service Agency.

Unemployment Compensation Account #

   
Please only numbers for the ten digit UC Account Number. No hyphens.

First Name

 
Please enter the first name of the primary contact person.

Middle Initial

Please enter the your middle initial of the primary contact person.

Last Name

 
Please enter the your last name of the primary contact person.

Title / Position

 
Please enter the current title / position of of the primary contact person at the Temporary Help Service Agency.

Business Address:

   
Please enter the address were the Temporary Help Service Agency is located.

City:

   
Please enter the city in which the Temporary Help Service Agency is located.

State:

 
Please enter the state in which the Temporary Help Service Agency is located.

Zip

   
Please enter a U.S. Postal zip code.

Telephone

   
Please enter the telephone number as
( XXX) XXX-XXXX.

Fax

 
Please enter the Fax number as
( XXX) XXX-XXXX.

E-Mail Address:

 
Please enter email as "yourname@isp.com".