Snelling Industrial Job Order Authors Email:(Required) Client Name:(Required)Called in by: _______________________________Client Phone:(Required)Client Email:(Required)Order Date: _______/________/_______ Time: ______:______ Author:________________________________Client Address:(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Reporting To:Address:Light ________ Heavy _______ E/O ________ Replacing ________________________Other Details: Rehire Reference Check MVR Draw Acct. HS Diploma Payrolling Hours:Duration:Pay Rate:Start Date: _______/_______/_______DS Type:Not RequiredUrineHairSwabOtherDS Panel:2 Panel3 Panel5 Panel7 Panel10 PanelOtherDS Location:In HouseClinicQuestOtherAmt. Billed for DS:BG Check:Not RequiredCityStateNationalOtherAmt. Billed for BG Check:Job Description and Title:(Required)Be descriptive about job duties, Do not enter “General Labor”Special Instruction or Charges:Orientation Information:Safety Training Videos Required:Conditions of Hire:NoneSteel Toe BootsMetatarsal GuardsSlip Resistant ShoesKhaki PantsBlack PantsWhite ShirtToolsOther, See Special InstructionsPPE By Snelling:NoneSafety GlassesHard HatChin StrapMet GuardsCut GlovesKnit GlovesLeather GlovesSafety VestOther, See Special InstructionsPPE By Client:NoneSafety GlassesHard HatChin StrapMet GuardsCut GlovesKnit GlovesLeather GlovesSafety VestOther, See Special InstructionsLift/Push/Pull(Required)Please selectNo Lift, Push, Pull Required5 – 20 lbs21 – 40 lbs41 – 60 lbsReps Per Hour(Required)Please selectLess than 10 per hour10 Repetitions30 Repetitions60 RepetitionsSurface(Required)Please selectDryWetFrozenMachines(Required)Please selectN/AConveyorNon ElectricalElectrical / GasTools(Required)Please selectHandsHand ToolPower ToolLevels(Required)Please selectFlatUnevenStairs / StepsSupervision(Required)Please selectDirectWithin ViewUnsupervisedClimate(Required)Please selectControlledVariedExtremeSurroundings(Required)Please selectRetailKitchenWarehouseFactoryGarage/ShopYardLandscapingFarmConstruction SiteFoundryTraffic ExposureDriverJanitorialThis field is hidden when viewing the formRisk Factor CalcThis job requires no previous work experience in this field.This job requires similar experience in this field. Green JobThis job requires 3 or more months of experience in this field. Yellow JobThis job requires a minimum of 1 year of verified experience in this field. Red Job By Name SS# Phone ETA SUB Int Ori BG DS Arv