Requester’s Name:

Title:

Telephone:

Fax:

Email:

Company:

Address:

Company Web Address:

Position Title:

Hours:

Start Date:

End Date:

Requested Hourly Rate:

Work Site Address:

Supervisor Name/Department:

Supervisor Telephone:

PC SKILLS:

Other:

Resumes to be provided for selection: Yes   No

Interviews: Yes   No

AU & Associates make selection: Yes   No

Temporary Assignment:

Temp to Hire Assignment:

Hire: