Please fill in the following form for future consideration as a supplier of the JJ PRO Program. The information being solicited by COMSYS in this form is for information purposes only. Completing this form does not obligate COMSYS to do business with any supplier providing such information, nor does it represent any commitment on the part of COMSYS. Supplier Registration Form Company Name Street 1 Street 2 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 West Virginia Wisconsin Wyoming Zip Phone Number Contact First Name Contact Last Name Contact Title Email Address Summary of Services Provided Geographic Areas Serviced Number of Contractors Currently Working at JJ Pro Total Number of Contractors Total Number of Internal Staff Do you currently have Workers Compensation Insurance Coverage? Yes No Do you currently have General Liability Insurance Coverage? Yes No Is your company incorporated? Yes No Is your company a Certified Diversity Supplier? Yes No Company Website URL