Stubs4Less™ Order Form
Customer Info
Customer Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
E-mail:
*
Passcode:
*
Please enter an alpha numeric passcode for order review.
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Order Info
Expedited Service:
Yes - Add $20
Date Order Needed:
*
-
Month
-
Day
Year
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Time needed by:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
# of Stubs Needed
*
Stub Package:
*
Stubs Only - Emailed (no additional fee)
Stubs Only - Faxed (no additional fee)
Stubs Emailed - W/ Verification (add $25)
Stubs Faxed - W/ Verification (add $25)
Stubs Only - Mailed (add $20)
Stubs Mailed - W/ Verification (add $45)
Verification Only - ($50)
Stubs Only - Pick Up (no additional fee)
Stubs - Pick Up W/ Verification (add $25)
Stubs Only - Delivered (add $20)
Stubs - Delivered W/ Verification (add $45)
Misc. Documents ($60)
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Stub Info
Pay Rate:
*
Hours Per Pay Period:
*
Last 4 of Social:
*
Pay Type:
*
Salary
Hourly
Commission
# of Dependants/Allowances
*
Tax Status
*
Single
Married
Pay Schedule:
*
Weekly
Bi-weekly
Monthly
Last Pay Date:
*
-
Month
-
Day
Year
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Name on Stub:
*
First Name
Last Name
Stub Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Employment Info
Employment Type:
*
Small Business Owner
Self-Employed
Other
State Of Employment:
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Hire date:
*
-
Month
-
Day
Year
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Position:
*
Employer Name
Employer Phone
-
Area Code
Phone Number
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer/Employment Details
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