Client (Employer) Registration 1/3

IMPORTANT: Placement Fees apply when offer is made to an applicant.


Basic Informations
































Client Occupational Information



Client's Spouse Information






Yes No
Date of position to start Yes No

Children / Elderly / Disabled Info

Enter age of .....

1. Person: 
Sex: 
Birthdate: 
Wt.%:
kg
Sp Need*:
Yes
2. Person: 
Sex: 
Birthdate: 
Wt.%:
kg
Sp Need*:
Yes
3. Person: 
Sex: 
Birthdate: 
Wt.%:
kg
Sp Need*:
Yes
4. Person: 
Sex: 
Birthdate: 
Wt.%:
kg
Sp Need*:
Yes

*Disabled / Special needs required.
%If the job requires lifting (elderly/ disabled) specify the weight of the patient.

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