Business Name:
Employee Name:
Supervisor:

Please specify times in the following manner.
08:00 AM 12:00 PM 01:00 PM 05:00 PM

You must type "I AGREE" in this box

I understand that I am to contact Employment Plus, Inc. upon completion of this assignment, and that if I do not do so, Employment Plus may assume that I am not then available for work, and thus are not eligible for Unemployment Benefits.