Business Services Request Form

Business Services Request Form

Date*

Federal Tax ID:*

Company Name:*

Company Website:

Company Address:*

Contact Name:*

Contact Phone Number:*

Contact Email Address:*

Are You A Private Employment or Staffing Agency*

Yes

No

Job Description:*

Position Title:*

Number of Positions Available:*

Target Start Date:*

Weekly Work Hours:

20 - 30 Hours

30 - 40 Hours

Other

Specific Work Schedule:*

SALARY RATE(OR RANGE):*

Public Transportation Accessibility:*

Yes

No

If Screenings are Required, Select All that Apply:

Credit

Drug

MVR

Background

Other

WorkSource DeKalb is an equal opportunity program. Auxiliary aids/services are available upon request to individuals

with disabilities. Persons with hearing impairments, all voice telephone numbers may be reached using TTY/TDD

equipment via the Georgia Relay Services at 1-800-255-0135. WSD is fully funded by the U. S. Department of Labor and

is a proud partner of the American Job Center Network.

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