<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("agreement1_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "Results", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(9) Dim arFormDBFields0(9) Dim arFormValues0(9) arFormFields0(0) = "Contact_Organization" arFormDBFields0(0) = "Contact_Organization" arFormValues0(0) = Request("Contact_Organization") arFormFields0(1) = "Contact_Title" arFormDBFields0(1) = "Contact_Title" arFormValues0(1) = Request("Contact_Title") arFormFields0(2) = "Contact_Email" arFormDBFields0(2) = "Contact_Email" arFormValues0(2) = Request("Contact_Email") arFormFields0(3) = "Contact_FirstName" arFormDBFields0(3) = "Contact_FirstName" arFormValues0(3) = Request("Contact_FirstName") arFormFields0(4) = "facility1" arFormDBFields0(4) = "facility1" arFormValues0(4) = Request("facility1") arFormFields0(5) = "agreement" arFormDBFields0(5) = "agreement" arFormValues0(5) = Request("agreement") arFormFields0(6) = "Contact_LastName" arFormDBFields0(6) = "Contact_LastName" arFormValues0(6) = Request("Contact_LastName") arFormFields0(7) = "facility" arFormDBFields0(7) = "facility" arFormValues0(7) = Request("facility") arFormFields0(8) = "date" arFormDBFields0(8) = "date" arFormValues0(8) = Request("date") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close FP_FormConfirmation "text/html; charset=windows-1252",_ "Form Confirmation",_ "Thank you for submitting the following information:",_ "agreement.htm",_ "Return to the form." End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> agreement

mednetservices.com home

Staffing Solution

Supplemental Staffing Agreement

Between

MedNet Healthcare Systems, Inc. and

Enter your Facility's Name

This agreement dated

Enter today's date

-- mm/dd/yy

between MedNet Healthcare Systems (as the provider) and

Enter your Facility's Name

(as the client) sets forth the conditions under which Supplemental Staffing Services will be provided to the client by the provider.

The services will be provided in accordance with the following:

Supplemental Staffing Services of Professionals such as Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants, state certified and experienced shall be provided to the client in accordance with a schedule (a.k.a availabilities) to be made available to the provider by the client on a weekly, biweekly, or monthly basis or as needed.

The provider agrees to furnish the client provable evidence of certification, background information as may be required by the client on any employee hired to work for the client.

The client agrees to treat the assigned employee as employee of record (hired by the client) of the client to be paid directly by the client, an hourly rate, as per the client’s payroll policy - weekly or biweekly whichever is applicable.

The client agrees to pay the provider, upon demand, within 30 days (please chose one out of the two plans we have available. Don’t forge to check the plan of your choice and also to initial it) Plan A is guaranteed for up to 30 days – if the employee leave your facility within 30 days, you will get a replacement at no cost to you.

Plan A Œ A one time fee of $275.00 per employee hired for your facility _____(init.)

Plan B Œ $395.00 per month for services rendered in accordance with this agreement for up to 5 temporary employees only per month. _____(init.)

The client agrees to conduct or require of the assigned employee, child/criminal clearance as well as proof of certification upon entering the client’s facility or in accordance with the client’s employment policy.

The client agrees to require of every assigned employee evidence of his or her current Physical Exam. The Physical Exam paper must show that the person concerned is in good physical condition and free from communicable disease.

The client agrees to verify state certification of every assigned employee with the State Board of Nursing or authorized government agency prior to or within seven days of employment to be sure each license is in good standing.

Client shall indemnify, defend, and hold harmless; the provider, its agents, officers, and employees from and against liability or loss and against all claims or actions based on or arising out of damage or injury, including death, to persons or property caused by or sustained in connection with the performance of duties by an assigned employee

In consideration of the above, the following parties are in agreement:

Do you agrees to the terms and conditions of this contract?

Yes, I Agree No, I disagree

Your relationship to the above named facility

First Name

Last Name

Title

Organization

E-mail