** = Required Field

Have you ordered from Optimum Staffing before? ** Yes No
Your First Name **
Your Last Name **
Your Title
Company Name **
Type of Business **
Street Address **
City**
State** Zip**
Phone Number **
Alternate Phone Number
Fax Number **
Email Address **
Website

(If Different From Above)
Billing Address
City State Zip
Phone Number
Fax Number

Best time to contact you **
How did you hear about Optimum Staffing? **

Type of Assignment ** Temporary Temp-To-Hire Permanent Placement Payroll Services
Start Date **
Estimated End Date **
Work Hours **
Shift **
Days of Work **
Number of Employees Needed **
Job Title **
Job Description **
Skills Required **
Rate of Pay **
Additional Info., Questions or Comments