| Section
1: Contact Information |
| Company name: |
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| Your first and last name: |
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| Title: |
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| Mailing address: |
Street or PO Box |
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City |
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State/Province |
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Zip/Postal Code |
| Company phone: |
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| Company fax: |
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| Your
email: |
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| Web site: |
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| How did you hear about us? |
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| Section
2: Company Information |
| How
many splits has your company completed in the last
12 months?
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| Total revenue from these splits:
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| Number
of in-house employees on company payroll
(e.g., recruiters,
consultants):
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| Total
number of employees, including contractors, on company
payroll:
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| Year company became active in the placement
industry:
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| Do you hire candidates from recruiters
on a contract or permanent basis?
Yes
No |
| Percentage of business is devoted to: |
% Contingency
% Contract
% Temporary
% Retained
% Other |
| Company's annual revenues: |
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Please list names/emails of
recruiters at your company who will be using our services:
Name Email
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| Network name:
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Reason for leaving:
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| Network name:
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Reason for leaving:
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Member of the following professional
associations:
(national, regional,
state or local associations, such as National
Association of Personnel Services)
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Normal fee schedule:
(e.g., 1% per thousand
with a cap of 36%)
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Following is a paragraph I would like displayed
to other Top Echelon Members about the specialty
areas and industries
I work: (This
is required before this form can be submitted.)
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| Section 3: References (We need
at least two references before
we can process your application.) |
|
List
any Top Echelon Members who will recommend you to
become a Top Echelon Member.
|
Name
Phone
Company |
| |
Name
Phone
Company |
|
OR
. . . List two placement firms you have made
splits with in the past.
|
Company
Phone
Name
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| |
Company
Phone
Name |
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OR
. . . List two professional references we may
contact, preferably client companies.
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Name
Phone
Company
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| |
Name
Phone
Company
|
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Please provide your personal contact
information
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Your full name
Home address
City
State
Zip
Home phone
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Section 3: Read our Agreement
for Services
|
Please
read our
Agreement
for Services,
and check one of the boxes to the right after
you've read the Agreement.
|
I've read the Agreement and I agree to abide
by it.
Yes, I agree
No, I don't agree
|
