About Our Employer of Record Company | Signature Back Office Solutions

W2

CONTRACTOR

NEW HIRE INFORMATION

W2 Contractor Form

Name(Required)

Prefix First Middle Last Suffix

Date(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Recruiting Firm Submitting(Required)

Worksite Client *If through VMS, please include the name of both the VMS and worksite Client. Ex: AnnLeo-ABC Assisted Living*(Required)

State Work Performed(Required)

Job Title(Required)

Regular Pay Rate(Required)

Regular Bill Rate/Net Bill Rate(Required)

Overtime Pay Rate(Required)

Overtime Bill Rate/Net Bill Rate(Required)

Special Instructions

Supervisor Name(Required)

First Last

Supervisor Phone Number(Required)

Supervisor Email(Required)

Sales Split

Recruiter Split

Background/Drug Screen Ordering Options

Level 1 (SS Trace, 7 Year criminal check from residential history, National Reg Sex Offender) - $30 (may vary per state)

Drug Screening (10 panel) - $32.50 (may vary per state)

Other

Additional charges may apply depending on your county/state of residence

Include an attachment

Max. file size: 9 MB.

Submitted By *(Required)

First Last

Email(Required)

Submitted Date(Required)

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From start to finish