Employer/Worksite Questionnaire Question Title * 1. Please provide your business information: Industry * Company Name * Address * Address 2 * City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Type of Business * Website Hours of Operation * Question Title * 2. Please provide your contact information: Name of Primary Point of Contact * Job Title * Email * Phone * Name of Secondary Point of Contact Job Title Email Phone Question Title * 3. Common Job Titles Available Question Title * 4. Number of People Needed Question Title * 5. Hourly Wage Question Title * 6. Job Skills Required Question Title * 7. If you have job descriptions, please attach here. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File If you have job descriptions, please attach here. Question Title * 8. Benefits Offered Vacation Sick Health Insurance Retirement Plan None Other (please specify) Question Title * 9. Language Requirements English Spanish Other (please specify) Question Title * 10. Drug Test Required Yes No Question Title * 11. Physical Exam Required Yes No Question Title * 12. Background Check Required Yes No If you answered Yes, please list is there are any background disqualifiers. Question Title * 13. Uniform Required Yes No If you answered Yes, is the uniform provided? Question Title * 14. Are you willing to be a work experience/internship site? Yes No If you answered Yes, please list positions available for participants and the minimum job skills required. Done
