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CLIENT COMPANY Information Sheet
Person completing these forms
(who we should contact for questions)
  		Person's Phone Number
Recruiter with Job Order (First/Last Name):  
Agency Name: Agency Code (if applicable):
Mail checks to:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
If this is your first contract placement with Top Echelon Contracting and another recruiter, or industry trainer, referred you to our service, please provide their contact information here. If this does not apply to you, leave this section blank.
Referring Person's name:
Referring Agency:
Referring Agency phone:
 		Referring Agency email:
Are you are a member of Top Echelon Network, Inc.? Yes No
Is this a split placement with another recruiting agency?
Client Company Name:
Website
What product or service does the company provide?
Billing Address:
City
  		State
  		Zip
Send Contract to (First/Last Name):  
Title:
Phone: Fax:
E-Mail:
Send Invoices to the ATTN of (First/Last Name):  
Title:
Phone: Fax:
Address at Work Location (no PO Boxes):
Bill Rate:$ /hour Overtime Bill Rate: $ /hour
We recommend that the recruiter negotiates a Conversion Fee Agreement directly with the client company so that the recruiter's conversion fee is in place in the event the client would like to hire the candidate as their employee. A suggested Letter Agreement for Contract Staff Recruiting Services is located here to assist the recruiter in this process.

If necessary, we can accommodate adding the recruiter's conversion fee into our Client Services Agreement. Please note however, Top Echelon Contracting does not take any responsibility for invoicing a conversion fee or enforcing any conversion fee in our Agreement.

Conversion Fee

CANDIDATE Information Sheet
Candidate Name (First/Last):  
Home Address: (Permanent - No PO Boxes):
City
  		State
  		Zip
Home Phone: Cell Phone:
Email: Job Title:
Is a drug screen required?
NOTE: Top Echelon Contracting conducts a drug screen and criminal background check on every healthcare worker we employ. The cost will be split between Top Echelon Contracting (30%) and the recruiter (70%). The recruiter's share will be deducted from his or her first recruiter check from Top Echelon Contracting.
Start Date:
End Date:
Pay Rate: $ /hr Per Diem: $ /hr  (if applicable) Overtime Pay Rate: $ /hr
Indicate if you want the candidate to receive Paid Leave Days. Note: This will reduce your recruiter commission.
Number of Paid Leave Days per year
Please include a Job Description for Workers' Compensation coverage. Please list all other relevant information concerning the candidate: 
RECRUITER CHECKLIST

Please check the appropriate column to indicate whether or not the recruiter has completed the item.

  Yes    No  
INFORMATION PERTINENT TO THE RECRUITER(S)
    Have you received a Quote from Top Echelon Contracting for this placement?
INFORMATION PERTINENT TO THE CANDIDATE
    Did you remind the Candidate that Top Echelon Contracting must receive all completed employment materials (contract, W-4, I-9, etc.) prior to their first payroll processing?
    Did you remind the Candidate that the he or she MUST undergo a background check?
    Did you remind the Candidate that each week's time sheet must be received by 1:00 P.M. EST Monday, or the processing of the paycheck will be delayed?
    Did you remind the Candidate that paychecks are mailed each Thursday?
INFORMATION PERTINENT TO THE CLIENT
    Did you confirm the client company bill rates for Regular and Overtime hours?
    Did you remind the Client Company that they will be receiving a Client Services Agreement from Top Echelon which must be signed and returned prior to the Contractor starting work?
    Did you remind the Client Company that invoices are sent on a weekly basis?
    Did you remind the Client Company that all invoices are "Due Upon Receipt"?
    Did you verify the duration of the contract with the Client Company (Start and End Dates)?
    Have you had the Client Company sign a specific CONVERSION FEE AGREEMENT with you?
    If necessary, would you like Top Echelon to include your specific CONVERSION FEE AGREEMENT in the Client Services Agreement we send to the Client? If so, please supply terms of the Conversion Fee to Top Echelon to be inserted into the Client Services Agreement.
NOTE: Top Echelon does not take a portion of your conversion fee; nor do we take any responsibility for invoicing a conversion fee in our contract or enforcing any conversion fee in our contract.
    Did you remind the Client Company that an authorized person MUST sign the Contractor's time sheet so it can be FAXED by 1:00 p.m. EST on Monday morning or processing of the Contractor's paycheck will be delayed?

NOTE: The information provided on these forms is used to generate binding legal documents. Please confirm that all information supplied to Top Echelon Contracting is accurate.

IMPORTANT!
Confirmation Address:
A copy of this data will be emailed to the address entered here (for your records).