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Client Staffing Request Form
Facility Information
Facility Name
*
Facility Type:
Nursing Home
Hospital
Clinic
Rehab Center
Home Care Agency
Other
Facility Address
Point of contact name
Point of contact title
Contact Phone Number
Email Address
Staffing Needs
What Positions are you requesting? (Check all that apply)
Number of staff needed per position:
Start Date for Staffing needs
Is this for:
Shifts & Scheduling
Shift times available
Minimum hours per shift:
Number of shifts per week
Preferred scheduling system or timesheet process (if any):
Credential Requirements
Required credentials for each role (e.g., CPR, BLS, State License, Vaccinations):
Are background checks or drug screens required before assignment?
Yes
No
Billing Information
Preferred method of billing:
Weekly
Bi-weekly
Monthly
Do you require a Master Service Agreement (MSA) or Vendor Contract to be signed?
Yes
No
Do you have a billing contact? (If yes, please provide name and email)
Additional Notes
Please describe any special skills or requirements for this assignment
How did you hear about ANS Staffing Agency?
Submit
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