Business Services Request Form

Date

mm/dd/yyyy

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

Job Description:

Position Title:

Number of Positions Available:

Target Start Date:

mm/dd/yyyy

Weekly Work Hours:

20 - 30 Hours

30 - 40 Hours

Other

Specific Work Schedule:

SALARY RATE(OR RANGE):

Public Transportation Accessibility:

Yes

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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