New Worksite
Please complete all the fields. If you need guidance, please ask your DPI Staffing representative.
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Date:
*
-
Month
-
Day
Year
(defaults to today's date)
Liaison Name:
*
Liaison Email:
*
example@example.com
WORKSITE & CONTACT INFORMATION
Is this for the YOUTH or ADULT program?
*
Youth
Adult
Contracted Service Provider
*
Please Select
PCC
IRCO
NAFY
POIC
Impact NW
New Worksite Name:
*
New Worksite Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Worksite Phone Number:
*
Please enter a valid phone number.
Timesheet Approver Name:
*
Timesheet Approver Phone Number:
*
Please enter a valid phone number.
Timesheet Approver Email:
*
example@example.com
TIMESHEET APPROVER INFORMATION
Timesheet Approver Name:
*
First Name
Last Name
Timesheet Approver Office Contact Number:
*
Please enter a valid phone number.
Timesheet Approver Cell Phone Number:
*
Please enter a valid phone number.
Timesheet Approver Email
*
example@example.com
Can we text the Timesheet Approver's Cell?
*
Yes
No
ADDITIONAL STEPS/RESOURCES
Safety Eval Completed?
*
Yes
No
If "No" When Will it Be Completed?
*
-
Month
-
Day
Year
Date
Upload the Worksite Agreement and any additional forms or informative materials:
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Additional Comments, Clarifications, and/or Information:
*
If there is absolutely nothing more to include to ensure this customer is serviced appropriately, please enter "N/A"
Signature
*
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