STAT Resources -- Staffing Request Form

STAFFING REQUEST FORM

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If your facility is in need of staffing, please take the time to fill out our request form. Thank you for choosing STAT Resources.

Today's Date:

Facility Name:

Contact Name:

Department:

Modality:

Address:

City:

State:

Zip:

Telephone:

Fax:

E-mail:

Equipment / Model Number:

Type of Order:

Immediate Supervisor:

Special Requirements (i.e. Dress Code):

Days/Hours of Assignment:

Start Date:

Length of Assignment:

How did you hear about STAT Resources?:

If other, please explain:



STAT RESOURCES What Health Care Staffing Should Be Corporate Office / Pittsburgh Division Newtown Division info@statresources.com