Please provide the following contact information:

Your Full Name
Your Title
Organization Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
FAX
Your E-mail
Web-Site Address

Are you willing to relocate the candidate?

Yes No Maybe

Company Description? [Plant Size; Revenues; Product Manufactured, etc]

Position Open, Salary Range & Job Description?

Position Available: Salary Range: Job Description:

Department Structure [How many in current department, who she/he reports to, etc]

Company Benefits:

Why is this position open  [New Position or Replacement]?