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):

      High Speed Internet (required):

    References:

      Reference 1 (required):

      Relationship:

      Phone (required):

      Reference 2 (required):

      Relationship:

      Phone (required):

      Reference 3 (required):

      Relationship:

      Phone (required):

    Additional Information: