Agency Employer Information

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1. Employer Name:
2. Address:
3. City:
4. State:	Please choose one Outside U.S. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
5. Zip or Postal Code:
6. Contact Person:
7. E-mail Address: (for confirmation):
8. Telephone:
9. Fax:

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10. Employer Name:
11. Job Title:
12.  Our  Job Series Number:	Choose from Table B on the left
13. Salary Range:	to
14. Country (if not US):
15. Job Location City (enter one ):
16. Job State Location:	Please choose one Outside U.S. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
17. Zip or Postal Code:
18. Other Job Locations (Cities, States):

19. Job Description (Comments)
Outline key: responsibilities, specific education, years of experience, and knowledge required. Be as brief or as detailed as necessary, but use no more than 100 words:

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20. Email:
21. Fax:
22. Telephone:
23. US Mail:

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