Address _________________________________________________________________________
Phone Number _______________________________ Fax _________________________________
Email __________________________________Website __________________________________
How long in Business?________________________ How Owned?__________________________
How many nurses work with your company? ________Office locations? ______________________
Recruiters Name __________________________ Number _________________________________
Email _____________________________ How Long You Work There?______________________
Best way to contact Recruiter ____________ What if I want to change Recruiter’s ______________
Quota of Contracts to sign ?__________________________ Fee for Signing? __________________
Different Dept’s to assist me? ________________________________________________________
How long are your usual assignments? 4, 8, 13 weeks?_____________________________________
Are your assignments country wide? ___________If not, which states do you offer employment in?
_________________________________________________________________________________
How Many assignments to choose from ?_______________________________________________
International assignments? ______Where?______________________________________________
Assistance after I take a contract? _____________________________________________________
Referral Bonus ?______________________ Hospital Referral Bonus? ________________________
Travel other Specialties? ____________________________________________________________
Travel Reimbursement? Per mile ___________________ Maximum__________________________
Do you provide health insurance? ________ Is it free? __________ Cost per month_____________
Monthly premium with spouse _________________When does it start? ______________________
Insurance Co __________________________________ Number____________________________
Rep. Name______________________________ Number__________________________________
Please explain the insurance _________________________________________________________
PPO_________________ HMO ______________Other ___________________________________
Deductible ____________________ Co-Pay ________________ Yearly Max __________________
Lifetime Max ____________ Pre-existing condition _________________________________ ______
Dental _________________________ Life Insurance________________ Amt_________________
Malpractice Insurance __________________
Do you pay weekly ______________ Biweekly ____________ Direct deposit _________________
Local checks ________________________________________
401K ____________ Match __________________________ Vested_________________________
How many hours are your usual assignments? ____________ Are these guaranteed? ____________
Do you guarantee OT? ________________ Do you provide double OT? ______________________
Cancellation Policy _______________________________ Float Policy _______________________
What are your usual hourly wages? ____________________________________________________
Do you provide bonuses after each assignment? __________________________________________
Any other bonuses? ________________________________________________________________
Tax Advantage Plan? _______________________________________________________________
Do you provide free private housing? _______________ Shared ____________ Furnished? _____________
What Furniture? ______________________________________________________________________
________________________________________________________________________________
Dishes, etc? ______________________________________________________________________
Appliances? ______________________________________________________________________
Housing Subsidy? __________________________ Keep extra? _____________________________
How many days can I move in before assign. starts? ___________________________________-
Are utilities paid? _________ If yes, which utilities _______________________________________
Do you provide a rental car? _______________________ Allowance? ________________________
Local transportation money ?_________________________________________________________
Do you provide CEU reimbursement? __________________________________________________
Do you provide License reimbursement? _______________________________________________
Do you cater to specific clients, eg OR Nurses? __________________________________________
Skills Checklist _________________________ Tests _____________________________________
Special License _________________________ Certifications _______________________________
References Needed _________________________________________________________________
Please provide comments about your company____________________________________________
. _______________________________________________________________________________
_________________________________________________________________________________
Better Business Bureau Results? ______________________________________________________
Other Nurse Experiences____________________________________________________________
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Referred by_______________________________________________________________________