Employers Checklist Form - Law Office of Stephen M. Perlitsh, PC

Name of our client that this information relates to:

Please complete the following questions:

1. Name of company or organization (exactly as it appears on Payroll Checks.

2. Name and title of person receiving correspondences on case.

3. Name and title of person signing, if different from #2.

4. Address of Company.

5. Addresses of places where services will be rendered, if different from #4. Please include addresses of hospitals where the physician may be obtaining privileges.

6. IRS Tax Identification number.

7. Job title.

8. Job Description. Provide as much detail as possible.

9. Salary and hours per week.

SALARY ($) HOURS PER WEEK:

10. Date Employment will commence.

MONTH: DAY: YEAR:

11. Date employment will terminate.

MONTH: DAY: YEAR:

12. Description of company. Three to four lines.

13. Year company was established.

14. Current number of employees.

15. Approximate Gross Volume. (Could state "In Excess of $ ") and provide an amount. Not needed if not for profit corp.

16. Telephone number (including area code).

17. FAX number (including area code)

18. Please advise whether you have an industry utilized, salary survey for the position.

19. Are more than 15% of your staff in H-1B status?

20. Number of individuals in H-1B status

21. Is there a Collective Bargaining Agreement (union) for the position? If yes, please provide the name of union and name and address of the Bargaining Representative.

If Yes, Union Name and Address is:

Name and Title of Person Completing Form:

I confirm this information is accurate to the best of my knowledge

Stephen M. Perlitsh ——- Betsy Arias ——- Stephanie DiPietro		_{Employer Checklist}
			Please complete all fields
			Name of our client that this information relates to: Please complete the following questions: 1. Name of company or organization (exactly as it appears on Payroll Checks. 2. Name and title of person receiving correspondences on case. 3. Name and title of person signing, if different from #2. 4. Address of Company. 5. Addresses of places where services will be rendered, if different from #4. Please include addresses of hospitals where the physician may be obtaining privileges. 6. IRS Tax Identification number. 7. Job title. 8. Job Description. Provide as much detail as possible. 9. Salary and hours per week. SALARY ($) HOURS PER WEEK: 10. Date Employment will commence. MONTH: DAY: YEAR: 11. Date employment will terminate. MONTH: DAY: YEAR: 12. Description of company. Three to four lines. 13. Year company was established. 14. Current number of employees. 15. Approximate Gross Volume. (Could state "In Excess of $ ") and provide an amount. Not needed if not for profit corp. 16. Telephone number (including area code). 17. FAX number (including area code) . 18. Please advise whether you have an industry utilized, salary survey for the position. 19. Are more than 15% of your staff in H-1B status? 20. Number of individuals in H-1B status 21. Is there a Collective Bargaining Agreement (union) for the position? If yes, please provide the name of union and name and address of the Bargaining Representative. If Yes, Union Name and Address is: Name and Title of Person Completing Form: I confirm this information is accurate to the best of my knowledge Useful Links:
	Stephen M. Perlitsh P.C. _{49 West 45th Street, Floor 6, New York, NY 10036} _{Telephone: (212) 840-3878 Fax: (917) 510-0872} _{Email: office@perlitsh.com} _{All information on this website © Stephen M. Perlitsh P.C.}