New Client Info Request

Welcome New Clients!  Looking for Staffing Support?  You’ve come to the right place!  Please provide us with  information about your company and your current or upcoming needs.  Once we receive your information we will contact you shortly.  Thank you in advance for your interest in AMS!

Legal Corporate Name of your Business/Organization: *

State of Incorporation:

Corporate Address (Street address, city, state, & Zip):

Corp. phone Number:

Corp fax:

Name of company owners/partners:

Main contact name at Corp office :

Main contact phone number:

Main contact email address:

dba Name of facility if different from Corporate Name:

Facility address (Street address):

Street address :

City:

State:

Zip:

Facility Main phone number:

Facility Main contact :

Facility Main contact Phone number:

Facility Main contact fax number:

Facility Main contact email address :

Name of Clinical Supervisor (CNO/DON/CLINICAL MANAGER):

Clinical Supervisor Phone:

Clinical Supervisor Email :

Clinical Supervisor Fax :

Name of person responsible for your company’s contract business::

Title of Contract person:

Contract person’s phone:

Contract person’s email:

Contract person’s Fax :

Name of Staffing Coordinator:

Staffing Coordinator Phone:

Staffing Coordinator Email:

Staffing Coordinator FAX:

Staffing Coordinator Cell :

What type services does your facility/organization offer?:

Please click on all (by holding down the control key) disciplines from the drop down menu that you utilize at your organization:: RNLVNCNANPPACRNARRTMASurgical TechPTOTPTACOTARad TechPhlebotomistMTMLTSocial WorkerWOCNEMTParamedicDental HygienistDental AssistantDental OfficeMedical Office/ClericalOther

Other discipline:

What are your current staffing needs?:

What shift preferences does your facility utilize?:

When do you need the staff requested above?:

What shift do you need filled?:

Date of your first need:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050

How many days /weeks needed?:

Are you interested in temporary staffing:

Yes

No

Are you interested in contract assistance:

Yes

No

Are you interested in temp-to-perm placement candidates?:

Yes

No

Are you interested in permanent placement candidates?:

Yes

No

Please describe your current orientation requirements for new staff:

Please list the acceptable uniforms/scrubs to be worn at your facility:

Scrub color preference:

Other:

Have you utilized any other staffing services in the past? :

Yes

No

If yes, please list previous services or companies used?:

What staffing services or companies do you currently use?:

What problems or concerns with former services have you had?:

How did you hear about us?: select...Internet searchJob FairProfessional Colleague (please name so we can thank them)Client Referral (please name so we can thank them)Professional JournalDirect MarketingLocal AdvertisingOther

Other:

How can we best provide assistance to you? :

Other comments/Explanation::

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