Employer's Job Description

Temporary/Transitional Job Permanent Job

* First Name:

* Last Name:

* L & I Claim #:

* Address 1:

Address 2:

* City:

* State:

* Zip:

* Doctor's Approval:

* Report to Work:

* Start Time:

* End Time:

* Hours Per Week:

* Dollar Amount $:

* Per:

* Location Address:

* Location City:

* State:

* Location Zip:

* Supervisor Name:

* Supervisor Phone #:

* Contact Phone #:

* Your Name:

Cc Line 1:

Cc Line 2:

Cc Line 3:

* Select Language: