wafla

Name * First Last
Contact requesting service. This will also be the contact that receives notification if a complaint has been received unless a different contact is listed below.
Name First Last
Contact that will receive notification a complaint has been submitted if different than the above contact.
Company Name *
Phone Number ### - ### - ####
Email *
Physical Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Please list the physical address you would like your consult to take place at.
Billing Address (if different from above)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Additional Posters (Request additional here)

You will be issued 4 posters for the first 50 employees then 2 per each additional 50. Additional posters will be billed at $2 each additional poster.
Additional Wallet Cards (Request additional here)

You will be issued a wallet card for each employee and ten percent additional. Additional wallet cards will be billed at .5 cents each per additional wallet card.
How many workers do you employ? All workers count, including seasonal workers. Please calculate by using the average number of employees you employ during peak season. *

The flat fee for the service is $300 per year, plus .50 cents per worker. You will be invoiced by wafla accordingly.
Do Not Fill This Out