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 Facility Enrollment Information

The beginning of the end of supplemental staffing as we know it is here. You are about to join facilities currently enjoying Staffing 2002© developed by MedNet Healthcare Systems. Feel free to complete this enrollment information.

When your information is approved, you will receive a phone call from the Scheduling Coordinator in charge of your State. Kindly have your initial availabilities ready for immediate attention.

Every item on this enrollment information is required to be approved, please make sure you complete them truthfully and honestly.

Contract Approval Contact Person

First Name
Last Name
Middle Initial
Title
Work Phone
E-mail

Your facility Scheduling Coordinator

First Name
Last Name
Middle Initial
Title
Work Phone
E-mail

Facility Information

Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Do you have the Administrator's permission to represent this Facility?

Yes No

Administrator's Information

First Name
Last Name
Middle Initial
Title
Organization
Work Phone
E-mail
URL

Enter today's date

-- mm/dd/yy

Thank you for taking the time to complete this enrollment information. Upon approval, you will receive a phone call initiating the beginning of a dependable and worry free relationship.

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