EMPLOYMENT AGENCY CLAIM FORM:
TEMPORARY SERVICE / SEARCH FIRM / STAFFING SERVICE
EMPLOYMENT AGENCY / PAYROLLING AGENCY / EMPLOYEE LEASING
TO:  MARYLOU PAOLUCCI & ASSOCIATES, P.C.
16 Trent Lane
Smithtown, NY 11787
Phone# 631-863-ATTY (2889)
Fax# 631-265-8982
Email: attycollect@optonline.net 

Please commence immediate suit on the usual 25% contingent fee terms:

YOUR COMPANY NAME:

Full Legal Corporate Name:

 

(including any d/b/a (doing business as)  or trade names)

Company Contact:

 

Address:

 

Phone, Email & Fax:

 

DEBTOR INFORMATION:
Account Number:

 

Full Name of Debtor Company:  
Last Known address on File:  
Amount Now Due: $  
(excluding interest or finance charges)

Any prior partial payments made: $

 

(furnish copies of any checks)

Additional Information Required Only for Temporary Labor Bills:

    Date of Earliest (Oldest) Unpaid Bill:

 
   

Additional Information Required Only for Permanent Placement Fees:

     Name of Candidate Placed:

 

   Start Date of Employment:

 
   

If fee is a percentage of the starting salary:

    What is the salary:

 

  What is the fee:

 

Guarantee Period:  Any guarantee period:

 

Did applicant last beyond guarantee?:

 

Nature of Any Dispute:

 

Name of our Placement Counselor

 Who Made Fee Agreement:

 

Name of person from Client Who 

Made Fee Agreement with our Counselor: 

 

Please furnish any written fee agreement or confirmation and invoice.

Additional Information require Only for Stolen Temps:

   Date that the Debtor hired the temp directly:

 

    Name of Temp:

 

If fee is percentage of the starting salary:

   *  What is the (presumed) salary: 

 

   *  What is the fee:

 

PLEASE FURNISH COPIES OF ANY SIGNED TIMESHEETS STIPULATING THE FEE.  
If the fee provisions are on the reverse, please furnish a copy of the reverse.

PLEASE MAIL OR FAX IF AVAILABLE:

  • Any Job Order
  • Any credit application
  • Any written agreement
  • Statement of Account with copies of outstanding invoices and time sheets
  • Any prior checks received
  • Any other information / any dispute

 

You will have an opportunity to print a copy of this form upon submission.
Please commence immediate suit on the usual 25% contingent fee terms.
Please validate your submission by typing the letters below into the box on the right. Letters are case sensitive.

Validation Code:

XPunbtL

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MARYLOU PAOLUCCI & ASSOCIATES, P.C.
THE CONTINGENCY LAWYERS
16 TRENT LANE, SMITHTOWN, NY 11787
Phone: (631) 863-ATTY (2889)
Fax: (631) 265-8982
Email: ATTYcollect@optonline.net 
Website: www.ATTYcollect.com

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