Non-Dairy Employee Request APS Representative's Name Business Name (required) Physical Address (required) Mailing Address (if different) Business Federal ID# (required) Business Entity Type (required) Individual Corporation Partnership LLC Other Business Contact Person (required) Phone # (required) Fax Number Cell Phone # (required) E-mail Address (required) Worker's Compensation Insurance Carrier Name (required) WC Policy # (required) WC Expiration Date: MM JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2023 2024 2025 2026 2027 2028 2029 2030 WC Contact Person (required) WC Contact Phone # (required) Banking Institution Name (required) Banking Contact Person (required) Banking Contact Phone # (required) Names of Authorized Signers (required) I understand that automatic or electronic payment of monthly fees will be required. (required) Yes No # of Entry-Level Employees Needed (required) Preferred Date of Need: MM JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2023 2024 2025 2026 2027 2028 2029 2030 Can Offer Competitive Work Hours (required) Yes No How Many Hours of Work per Week (required) Competitive Hourly Wage (required) Work Shift for New Employee(s) (required) Job Duration (required) Please briefly describe your business and the tasks to be performed (attach additional sheets as necessary) Equipment Operation Skills Needed (attach additional sheets as necessary) Distance from Worksite (required) On-site Other Heat, Electricity, Clean Water (required) - Yes No Smoke Detectors in All Bedrooms (required) - Yes No Carbon Monoxide Detector (1 Central) (required) - Yes No First Aid Kit (required) - Yes No 2:A Fire Extinguisher (required) - Yes No Telephone for 911 Emergency (required) - Yes No Stove & Refrigerator (required) - Yes No Dishes, Glasses, Cooking Utensils (required) - Yes No Vacuum Cleaner, Broom, Cleaning Tools (required) - Yes No Kitchen Table & Chairs (required) - Yes No Dressers, Beds w/Linens & Blankets, Bath Towels (required) - Yes No Living Room Couch or Chair (required) - Yes No High Speed Internet (required) - Yes No Reference 1 name (required) Relationship Phone # (required) Reference 2 name (required) Relationship Phone # (required) Reference 3 name (required) Relationship Phone # (required) Please provide other information that could help us identify and train prospective employee(s): I hereby consent to the processing of the data that I have provided to respond to my request. Send Downloads NON-DAIRY EMPLOYEE REQUEST DOWNLOAD PDF Other Request dairy employees TN Visa employees
