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?
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The Web
MSP or VSM
A Client
A Vendor
By and agency staff member
Has your company been in business for at least 12 months?
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Yes
No
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.)?
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Yes
No
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?
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Yes
No
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.
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A PEO/EOR is not used
General Liability, Professional Liability, and Workers’ Compensation
Workers’ Compensation Only
Are you Joint Commission certified?
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Yes
No
No, but in progress
Date Certified
-
Month
-
Day
Year
Date
Are you looking to subcontract?
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Yes
No
Are you looking to partnership?
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Yes
No
Does your company use a third party invoice factoring or a payroll funding service?
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Yes
No
Company Legal Name
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DBA
Street Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Federal Tax I.D.
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Date Company Started
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-
Month
-
Day
Year
Date
Type of Business
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Corporation
Partnership
Limited Liability Company
Limited Liability Partnership
Limited Partnership
Sole Proprietorship
Parent/Affiliate Company
State Incorporated In
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Website URL
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Primary Contact Name
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Primary Title
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Primary Phone #
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Please enter a valid phone number.
Primary Email
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example@example.com
Owner's Name
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Owner's Phone
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Please enter a valid phone number.
Owner's Email Address
*
example@example.com
Owner's Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Annual Sales 2023
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Annual Sales 2022
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States you staff for Temp, Direct Placement, Per Diem, Travel
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Staff you can provide
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Nurses
Allied
Physicans
Non Clinical
International
Other
Nursing staff you provide
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RN
LPN
CNA
Certified Med Tech
Registered Med Tech
Personal Care Assistant
Nurse Assistant
Clinical Support Services
Do not provide nursing staff
Allied staff you provide
Non-Clinical staff you provide
Top staffed positions (Profession/Specialty)
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Hiring Practices
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Client Reference 1 Name
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Client Reference 1 Title
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Client Reference 1 Company Name
*
Client Reference 1 Phone #
*
Please enter a valid phone number.
Client Reference 2 Name
*
Client Reference 2 Title
*
Client Reference 2 Company Name
*
Client Reference 2 Company Phone #*
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Please enter a valid phone number.
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
*
Submit
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