Client Form Direct Placement

You will be prompted to fill out billing information after this form is completed on the submission page. To complete the process you must fill out our secure billing collection form.

Direct Placement Search Client Form

Direct Placement Search Services

First Name*
Last Name*
Service Location*
Title
Company
Mobile
Office
Best Number to Contact*
Email*
Office Address*
Street Address Address Line 2 City State ZIP Code
How Did You Hear About Us?
Referred By (If Applicable)*
Provide details on use of services:
Indicate the position you will be using Steelman Staffing & Associates for.
Location of Service (if other than address listed above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client Name 2
First Last
If applicable provide second contact at company.
Mobile
Office 2
Best Number to Contact 2
Email 2
Schedule and Assessment
Please be as descriptive as possible when filling out the hours of care you will need. Specify if you will need a.m., p.m., or 24 hour shifts.
Date of Service (if not sure please indicate)
MM slash DD slash YYYY
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Special Requests
For All Locations: Please print full documents for your records. By entering my initials in the box below, I hereby agree to the terms and conditions stated above in this Client Application and Agreement and to all the terms and conditions in the Steelman Staffing & Associates Agreement.*

Please print and retain all of our agreements as listed at the top of this page.
Additionally, by entering my initials in the box below I: (1) agree to provide all of my necessary billing information to Steelman Staffing & Associates; (2) agree to provide Steelman Staffing & Associates with a valid credit card for billing or have made pre-approved invoice terms in writing; (3) understand and agree that Steelman Staffing & Associates shall charge my credit card or will be invoiced for all fees, charges and costs pursuant to the Steelman Staffing & Associates Agreement; and (4) agree to pay all such fees, charges and costs on my credit card or within terms of written agreement to Steelman Staffing & Associates.*

Fees for employment services will be based on the original booking confirmation. Should the hours be extended they will be audited in our weekly billing based off time card review and will automatically charged to your billing credit card.
By entering my initials below I understand: On all Temporary bookings if scheduled service is cancelled after 5pm the day prior to service client will be billed for 4 hours of service fees for the scheduled time and if cancelled the same day client will be charged the full day of service fees.*
**Please print and retain a copy of your completed Client Application for your records.**

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Direct Placement Search Client Form

Schedule and Assessment

SERVICES

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