Headcount Management

Please fill out all of the fields below and press the Submit button.

Fields marked in orange are required to enter a new assignment.

Employee Information

Employee Start Date *
/ /

Employee Name*

Job Title*

Type of Placement* (i.e warehouse, IT, clerical, etc.)

Workers Comp. Code* (if known)

Address*

City*

State*

Zip*

Phone Number*

Email Address

Recruiter Information

Your Name*

Company Name*

Split Recruiter

Invoice Information

Contact Name*

Company Name*

Address*

City*

State*

Zip*

Phone Number*

Fax Number

Contact Email

Work Location Information

(Check if the same as above)

Contact Name*

Company Name*

Address*

City*

State*

Zip*

Phone Number*

Fax Number

Contact Email

Rate Information

Company Bill Rate*

Employee Pay Rate*

Overtime Exempt?*

Yes

Overtime Bill Rate*

Special Instructions/Comments

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