Potential Client Information Form
Please fill out this form and Carolina Nurse Staffing, LLC will be in contact with you shortly to speak with you about becoming a client and assisting with your companies staffing needs!
Today's Date
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Month
-
Day
Year
Date
Facility Details
Company name
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Contact Number
*
Company Email
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example@example.com
Website URL
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Positions/ Roles Needed
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Registered Nurse (Bachelor)
Registered Nurse (Associates)
Certified Nurse Assistant (CNA)
Licensed Practical Nurse (LPN)
Med Aide
Med Tech
Other
Total Number of Employees Needed (Estimated)
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Are you currently using one or more Staffing Agencies?
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Yes
No
Company Description:
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Please list any questions or concerns you have:
Contact Person Details
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Company Representative Name
*
First Name
Last Name
Company Representative Email
*
example@example.com
Company Representative Signature
*
Date Signed
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-
Month
-
Day
Year
Date
Print Form
Submit
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