SCWIJobs

Recruiter Name

First Name

Last Name

Recruiter Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Recruiter Phone Number

(###)

###

####

Recruiter Date of Birth

MM

DD

YYYY

Applicant Name

First Name

Last Name

Applicant Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant Phone

(###)

###

####

Applicant Date of Birth

MM

DD

YYYY

Do You Operate as a(n)

Individual

Partnership

Corporation

Association

Other

If You Perform One Or More of The Following Activities with Respect to Migrant Workers, Check All That Apply

Solicit

Recruit

Hire

Furnish Workers

House

Transport

Do You Charge Workers a Fee for Any of the Activities You Checked Above

Yes

No

Do You Collect a Fee or Receive Any Benefits From Employers For Whom You and Your Crew Work

No

Yes

Signature Date

MM

DD

YYYY