Client Designated Employer Representative (DER)

Company Name:
Company Address: Company Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Company Contact: Company Contact: First Last
Phone: Phone: - ### - ### ####
Email:
Number of Designated Employer Representatives (DER):
DER #1: DER #1: First Last
DER #1 Phone Number: DER #1 Phone Number: - ### - ### ####
DER #1 Email:
DER #2: DER #2: First Last
DER #2 Phone Number: DER #2 Phone Number: - ### - ### ####
DER #2 Email:
DER #3: DER #3: First Last
DER #3 Phone Number: DER #3 Phone Number: - ### - ### ####
DER #3 Email:
Comments: