Staffing Agency Application for Potential Partnership with Holt Law
Section 1: Agency Information
1. Agency Legal Name / Doing Business as:
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2. Primary Contact Name & Title:
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3. Email
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example@example.com
4. Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
5. Agency Website:
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6. Main Office Address:
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7. Year Founded:
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8. States/Regions where your agency is licensed to operate (please list all):
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Section 2: Agency Specialization & Experience
1. Please list all license types or professional types that you would like to staff for:
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2. How many years of experience does your agency have in healthcare staffing?
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3. Please provide a brief description of your agency's mission and values.
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4. How does your agency ensure the quality and competency of placed staff? (e.g., rigorous screening, continuous training, etc.)
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5. Do you have written contracts, procedures and systems in place to communicate with your staffed individuals, and our clients?
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6. How do you handle disputes with staffed individuals or our business clients?
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Section 3: Licensing & Compliance
1. Does your agency have current professional liability insurance?
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Yes
No
If Yes, please provide coverage limits (e.g., $1M/$3M).
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2. Does your agency conduct background checks on all placed staff?
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Yes
No
If Yes, please briefly describe the scope of your background checks (e.g., criminal, education, employment verification).
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3. How does your agency ensure compliance with all applicable federal, state, and local employment laws and regulations (e.g., HIPAA, OSHA, labor laws)?
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Section 4: References & Testimonials
Please provide three (3) professional references from current or past clients, or reputable colleagues (preferably healthcare organizations).
Reference 1
Name
First Name
Last Name
Title
Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Reference 2
Name
First Name
Last Name
Title
Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Reference 3
Name
First Name
Last Name
Title
Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
2. May Holt Law contact these references?
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Yes
No
3. Do you have any client testimonials or case studies you would like to share? If so, please provide links.
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Section 5: General Information
1. Has your agency ever been involved in any significant litigation or regulatory actions related to staffing or employment practices?
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Yes
No
If Yes, please explain the circumstances.
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2. Is there any additional information you would like Holt Law to know about your agency or background?
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Acknowledgement and Agreement
By submitting this application, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that submitting this application does not guarantee a partnership with Holt Law. I authorize Holt Law to verify any information provided herein and to contact the references listed.
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Name
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First Name
Last Name
Title
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Date
*
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Month
-
Day
Year
Date
Submit
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