Your Name (required):

Your Email (required):

APS Representative Name:

Subject: NON-DAIRY EMPLOYEE REQUEST


BUSINESS INFORMATION:

    Business Name (required):

    Employer Federal ID# (required):

    Business Contact Name (required):

    Employer Entity Type (required):

    E-mail Address (required):

    Re-enter E-mail Address (required):

    Phone Number (required):

    Mobile Number:

    Fax Number:

    Physical Address (required):


    Mailing Address (if different):


BANK AUTOMATIC PAYMENT INFO:

    Banking Institution Name (required):

    Banking Contact Person (required):

    Banking Contact Phone Number (required):

    Names of Authorized Signers (required):

WORKER'S COMP INFO:

    Insurance Carrier Name (required):

    Policy # (required):

    Expiration Date (required):

    Contact Info (required):

WORKER INFORMATION:

    # of Entry-Level Employees Needed (required):

    Can Offer 60+ hrs. of work per week (required):

    Date When Employees Will Be Needed (required):

    Hourly Wage (required):

    Please describe your business and the tasks to be performed (Briefly describe your operation and tasks to be
    performed.):

    Equipment Operation Skills Needed:

HOUSING:

    Distance from Worksite (required):

    Smoke Detectors in All Bedrooms (required):

    Heat, Electricity, Clean Water (required):

    Carbon Monoxide Detector (1 Central) (required):

    First Aid Kit (required):

    Fire Extinguisher (required):

    Telephone (required):

    Dishes, Glasses, Cooking Utensils (required):

    Kitchen Table & Chairs (required):

    Vacuum Cleaner, Broom, Cleaning Tools (required):

    Stove & Refrigerator (required):

    Dressers, Beds w/Linens & Blankets, Bath Towels (required):

    Living Room Couch or Chair (required):

    TV with Satellite or Cable (Spanish Channels) (required):

References:

    Reference 1 (required):

    Relationship:

    Phone (required):

    Reference 2 (required):

    Relationship:

    Phone (required):

    Reference 3 (required):

    Relationship:

    Phone (required):

Additional Information: