Wayne Corporation

Consultants/Brokers

Organization Name:

Contact Name:

Phone Number:

Street Address:

City:

State:

Zip Code:

Website Address:

Type of Business:

Number of Employees:

Multiple Locations:

Yes No

If yes, where are they located and how many employees in each location?:

Does the company have an existing EAP?:

Yes No

Additional Services:

Enhanced Work-Life
Enhanced Legal/Financial
Enhanced Elder Care/Child Care
Substance Abuse Program
Management/DOT Compliance

Other information that would be helpful: