Agency Consent Form

Agency Consent Form

As you are joining the CTM Medical Staff Bank, we will need to submit a Notice of Intention to Hire to your current agency to facilitate your transfer onto the bank.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Your Current Job Role
Your Current Band
Your Specialty
Current Agency Name
Agency Consultant Email
example@example.com
Agency Consultant Name
Should be Empty: