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Staffing Order Form

Today's Date: 7/31/2010

Hospital / Clinic
Address
Billing Address
Contact Person/Title
Contact Email
Contact Telephone
Report To Person/Title
Report To Person's Phone
JOB REQUEST INFORMATION
This Order is for Phoenix/Scottsdale
West Valley
East Valley
Tucson
Name of Position
This position is a Temp to Direct
Temp
Direct Hire
Per Diem
Position Start Date
Length of Assignment
Days of Week
Hours
Pay Rate
Employee Screening Yes    No
Type:
Drug
Fingerprinting
Background
Credentialing
Job Description and Special Skills Required
Dress Code
Remarks about your Company
Driving Directions


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