Affiliate Vendor Screening Questionnaire-WTS Health

Affiliate Vendor Screening Questionnaire

Are you a staffing agency looking to partner with us? Join our affiliate vendor network at WTS Health by completing our screening questionnaire, and we will get in touch.
How did you hear about us?
Has your company been in business for at least 12 months?
Do you assume sole responsibility as the employer of record for the payment of wages to your temporary employees (W2) and for the withholding of applicable federal, state and local income taxes, the making of required Social Security tax contributions, and the meeting of all other statutory employer responsibilities (including, but not limited to, unemployment and workers compensation insurance, payroll excise taxes, etc.)?
Do you maintain general liability insurance and professional liability insurance with limits equal to or greater than $1,000,000 per occurrence and $3,000,000 aggregate and will provide certificates of insurance naming WTS Medical Staffing, LLC as an additional insured?
Does your agency use a PEO/EOR to provide any portion of the insurance coverage for the staff you provide? If so, please select which lines of coverage the PEO/EOR provides.
Are you Joint Commission certified?
Date Certified

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you looking to subcontract?
Are you looking to partnership?
Does your company use a third party invoice factoring or a payroll funding service?
Company Legal Name
DBA
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Federal Tax I.D.
Date Company Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Business
Parent/Affiliate Company
State Incorporated In
Website URL
Primary Contact Name
Primary Title
Primary Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email
example@example.com
Owner's Name
Owner's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Email Address
example@example.com
Owner's Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Annual Sales 2023
Annual Sales 2022
States you staff for Temp, Direct Placement, Per Diem, Travel
Staff you can provide

Other
Nursing staff you provide
Allied staff you provide
Non-Clinical staff you provide
Top staffed positions (Profession/Specialty)
Hiring Practices
Client Reference 1 Name
Client Reference 1 Title
Client Reference 1 Company Name
Client Reference 1 Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Client Reference 2 Name
Client Reference 2 Title
Client Reference 2 Company Name
Client Reference 2 Company Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Does your company identify an is certified as any of the following?
Small Business, LBGTQ, Veteran Owned Small Business, Minority Owned- please list
Please verify that you are human
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