Agency's Full Legal Name * required

First Name * required

Last Name * required

Email * required

Please list all DBAs or subsidiaries that are covered under this application (enter N/A if not applicable). * required

Please list all other DBAs under your parent organization that are not party to this application (enter N/A if not applicable) * required

Do you have a contract with a professional employer organization (PEO), agent of record (AOR), employer of record (EOR) * Yes No required

Address Line 1 * required

Address Line 2 * required

City * required

State * Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific required

Zip Code * required

Federal Tax ID * required

Type of Business * Limited Liability Company (LLC) Corporations S Corporations Sole Proprietorship Partnership required

State of Incorporation * Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah U.S. Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific required

Main Phone Number * required

Website * required

Number of Employees * 1-50 50-100 100-300 300-500 500+ required

Number of Contract Employees * 1-50 50-100 100-300 300-500 500+ required

Northeast *
Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont New Jersey New York Pennsylvania None of these required

West *
Arizona Colorado Nevada New Mexico Utah Wyoming Alaska California Hawaii Oregon Washington None of these required

Midwest *
Illinois Indiana Michigan Ohio Wisconsin Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota None of these required

South *
Delaware Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia Alabama Kentucky Mississippi Tennessee Arkansas Louisiana Oklahoma Texas None of these required

What States do you do the most staffing in to date? * required

Gross Annual Sales * Gross Annual Sales $0 – $5 million $5 – $10 million $10 – $20 million $20 – $50 million $50 – $100 million $100 – $250 million required

Can you meet our minimum insurance requirement for general and professional liability based on the staff you support? ($1M/$3M for all – some partners require $3M/$3M cyber insurance) * Yes No required

Can you provide at least 2 references from clients? * Yes No required

Are you Joint Commission certified? * Yes No required

Are you planning to become Joint Commission certified?

Are you recognized for any of the following Business Diversity Classifications? *
Disability-Owned Business Enterprise (DOBE) Disability-Owned Disabled Veteran Business Enterprise (DVBE) Service Disabled Veteran-Owned Business (SDVOB) Service Disabled Veteran-Owned Small Business (SDVOSB) Veteran-Owned Business (VOB) Vietnam Veteran-Owned (VVO) Disadvantaged Business Enterprise (DBE) Economically Disadvantaged Woman-Owned Small Business (EDWOSB) Historically Underutilized Business Zones (HUBZone) SBA-8(A) Certified Small Business Enterprise (SBE) Small Disadvantaged Business Enterprise (SDBE) Certified Woman Business Enterprise (WBE) Lesbian, Gay, Bisexual, Transgender Business Enterprise (LGBTE) Woman-Owned Small Business (WOSB) Certified Minority Business Enterprise (MBE) None Other required

Please list all the roles you staff (EX: Local Nursing, Travel Nursing, Allied Health, Revenue Cycle, Healthcare IT, Behavioral Health, Human Services, Education Support Staff, etc.) *
Allied Clinical Non-clincial Facilities & Services IT Locum Tenens Dietary/Dieticians Environmental Services Homecare Admin/Corporate required

Which of the above are your primary expertise? * required

Of the above staffing categories, do you staff any hard to staff or niche roles that should be noted? * required

What type of staffing do you provide? *
Contract Per Diem Temp-to-hire Interim Permanent Placement required

Will any of the staff you provide come from other agencies? * Yes No required

Have you ever provided staffing services to the federal government? * Yes No required

First Name * required

Last Name * required

Email * required

Phone * required