Please complete the information requested below and click submit. If this is an urgent request, you should also share this with your assigned ADP District Manager.
REFERRAL INFORMATION:
* Company Name:
Date:
* Address:
* City:
State:
Select One
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* Zip:
* Contact First Name:
* Contact Last Name:
Title:
* Phone:
E-mail:
Frequency of Payroll:
Select One
W=Weekly
B=Bi-Weekly
S=Semi Monthly
M=Monthly
O=Other
No. of Employees:
Current Payroll Method:
Select One
1=Manual
2=Software
3=CPA
4=SVC Bureau
5=Leasing
6=Other
Contact banker prior to sales call:
Yes
No
* Required
BANK ASSOCIATE INFORMATION:
Banker Email
Employee Name:
Phone:
Branch Name:
Branch No.:
Do not put zeros in
front of Branch No.
Cost Center:
Region No.:
District No.:
Banker ID:
Business Line:
Comments: (maximum 250 characters)
Referrals are delivered to ADP District Managers within 24-48 hours from the date the lead form is submitted on-line. If this is an urgent request, please contact your ADP District Manager directly after submitting this form.
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