Employment Client Extension Form

EMPLOYMENT CLIENT EXTENSION FORM

Client Name:    Client Contact:

Client Information

Employee Information

Phone:    Email:

Position & Assignment Details

Reporting Manager:

Original Assignment Start Date:    Original Assignment End Date:

Proposed Extended End Date:    Extension Duration (weeks/months):

Typical Work Schedule / Hours:    On-site Requirement: Required

Compensation, Billing, & Expenses

Employee Pay Rate (if applicable):

Client Billing Rate:    Invoicing Frequency:

Scope of Work & Responsibilities

Extension Terms & Conditions

This extension modifies the original assignment agreement between the Client and Employer for the Employee named above. Unless otherwise amended in writing, all terms and conditions of the original agreement remain in full force and effect for the period of the extension. The parties expressly acknowledge and agree that:

1. All confidentiality, non-solicitation, intellectual property, and security obligations applicable under the original agreement continue to apply throughout the extension period.
2. Either party may terminate the assignment during the extension period in accordance with the notice provisions of the original agreement unless otherwise set forth herein.
3. If the Client requests additional duties materially outside the original scope, the Employer will notify the Client of required rate or resource adjustments in writing prior to commencement.

Rate Adjustment Required? Yes    New Billing Rate (if checked):

Overtime Authorization: Client authorizes pre-approved overtime at agreed rate

Employment History (Employee)

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation Date:

Professional References

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Disclosures & Policies

At-Will Employment: Employee understands that the staffing relationship or employment with the Employer is at-will and may be terminated by either party at any time, with or without cause, subject to the written terms of any separate agreement between the Employer and Client. Nothing in this Extension Form alters at-will status unless expressly set forth in a signed amendment.

Equal Opportunity: The Employer and Client maintain equal opportunity practices; employment and assignment decisions shall be made without regard to legally protected characteristics in accordance with applicable law.

Background and Reference Checks: Employee authorizes the Employer and Client to make inquiries of prior employers, education providers, and references, and to conduct background checks where permitted by law. Employee certifies that information provided herein is true and understands that material misrepresentation may result in termination of the assignment.

Employee Authorization to Conduct Checks: I authorize contact with prior employers and the conduct of background checks and drug screening where applicable.

Applicant / Employee Certification

I certify that all information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that falsification or omission of material facts may result in removal from assignment or termination. I further acknowledge that I have read and understand the terms of this extension and the underlying assignment agreement.

Employee Printed Name:    Employee Acknowledgment Date:

Administrative Approvals

Employer Approval Date:

Client Approval Date:

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