Company Name:
Address:
City: State: Zip:

Company Phone:
Company Fax:

Contact Name:
Contact Phone:
Contact Email:

Type of Business:
How long have you been in business?

Average Payroll Amount:

Less than $600
$600 to 1,000
$1,000 to 2,000
$2,000 +

Frequency:

Weekly
Bi-Weekly
Twice a Month
Monthly

Average Annual Payroll:

How many employees do you have:
Employee Category 1 Duties:
Employee Category 2 Duties:
Employee Category 3 Duties:
Employee Category 4 Duties:

Current Payroll Processor:

In-House / Self
Accountant / Bookkeeper
PEO / Staff Leasing
Non-PEO Processor (i.e. ADP, Paychex)
None

How did you hear about us:

Additional Comments:
Enter any comments or other information here...