TEC Client Billing Form

Select Item
- Client Billing Form
- Pay Rate Change
- Markup Change
- Terms Change
- Contact Change
- Service Charge Only
Branch Office
Date:
MM slash DD slash YYYY
Author:
Author Email:
Contact Name:
First Last
Approved By:
First Last
Contact Phone:
Contact Email:
Client Name:
Client Address:
Street Address City State / Province / Region ZIP / Postal Code Country
Special Conditions:
Motor Vehicle Report (MVR):
Markup Details:
Regular Markup % Payrolling Markup % Overtime Markup % Other Markup % See Notes
Please enter N/A on spaces not being used.
Markup Change:
Previous Markup: New Markup:
Markup Change Authorized By:
First Last
Assignment Details:
Roll Over Hours Pay Rate # Poss Placements Duration
Pay Change:
Old Pay Rate: New Pay Rate:
Pay Change Authorized By:
First Last
Client Status
Client Type:
Work Comp Class Code
Billing Contact:
First Last
Billing Contact Email:
Billing Contact Phone:
Billing Contact Fax:
Billing Address:
Same as Client Address

Street Address City State / Province / Region ZIP / Postal Code Country
Drug Screen:
DS Amt. Billed:
Enter $0 if the cost is built into the rate.
Background Check:
BG Check Amt. Billed:
Enter $0 if the cost is built into the rate.
Workers Compensation Code:
Terms:
Payment Type:
ACA Charge Per Hour: If any
Invoice Delivery:
Email Invoice To:
Last Placement:
Please enter the date of last placement. This can be found in Safari or you can contact the Branch Manager.
Credit Process:
- Application
- Reference Ltr
- CC Account
Pay Day:
Vendor Management System:
Third Party Vendor:
Third Party Terms Information:
Additional Notes:

Translate »