Contact Person

First Name

Last Name

Phone Number

(###)

###

####

Extension

(###)

###

####

Full Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are there seasonal or contract employees (e.g. Independent Contractors)

Yes

No

Are 50% or more of the employees from the same family?

Yes

No

Are all employees and owners covered by Workers Compensation (WSIB)?

Yes

No