Skip to content
Employer/Worksite Questionnaire
*
1.
Please provide your business information:
(Required.)
Industry
*
Company Name
*
Address
*
Address 2
*
City/Town
*
State/Province
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
*
Type of Business
*
Website
Hours of Operation
*
*
2.
Please provide your contact information:
(Required.)
Name of Primary Point of Contact
*
Job Title
*
Email
*
Phone
*
Name of Secondary Point of Contact
Job Title
Email
Phone
*
3.
Common Job Titles Available
(Required.)
*
4.
Number of People Needed
(Required.)
*
5.
Hourly Wage
(Required.)
*
6.
Job Skills Required
(Required.)
7.
If you have job descriptions, please attach here.
Choose File
No file chosen
*
8.
Benefits Offered
(Required.)
Vacation
Sick
Health Insurance
Retirement Plan
None
Other (please specify)
*
9.
Language Requirements
(Required.)
English
Spanish
Other (please specify)
*
10.
Drug Test Required
(Required.)
Yes
No
*
11.
Physical Exam Required
(Required.)
Yes
No
*
12.
Background Check Required
(Required.)
Yes
No
If you answered Yes, please list is there are any background disqualifiers.
*
13.
Uniform Required
(Required.)
Yes
No
If you answered Yes, is the uniform provided?
*
14.
Are you willing to be a work experience/internship site?
(Required.)
Yes
No
If you answered Yes, please list positions available for participants and the minimum job skills required.
