Staffing Application
Account Type
*
Applicant
Business
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Are you interested in temporary or contract work?
Temporary
Contract
Kindly provide supplementary information.
Applicant Experience
Please Select
Nurse
Nurse Practitioner
Medical Director
Aesthetician
Laser & Weight Loss Tech
Medical Aesthetician
Phlebotomist
IV Technician
Relevant license and any certifications (File Upload)
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Choose a file
Select multiple files at once to add/upload more than one files
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of
Company Name:
Mailing Address
example@example.com
Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EIN#
Number of Employees:
Briefly describe the type of talent you are looking for or add additional notes if needed .
Staff Needed
Please Select
Nurse
Nurse Practitioner
Medical Director
Aesthetician
Laser & Weight Loss Tech
Medical Aesthetician
Phlebotomist
IV Technician
Does your Malpractice insurance cover another Subcontractor?
Yes
No
If "Your Malpractice insurance covers another Subcontractor", submit an insurance certificat
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Drag and drop files here
Choose a file
Cancel
of
Coverage Dates
Payment Information
Monthly Membership Fee: $399 /Business
Payment Information
Applicant Membership Fee $199.00/ Applicant
Signature
*
Submit
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