PRN Intake Form
New Hire Intake
PRN Name
Label
Discipline
Email Address
Cell Phone Number
Home Street Address
Home City
Home State
Home Zip Code
Negotiated Hourly Rate
Type of Employee
W2
1099
Counties Willing to Cover
Are you dual licensed?
Yes
No
Unknown
If yes, specify below which state.
If you answered yes above that you are dual-licensed, please list which state?
Currently a DOR with another company?
Yes
No
Unknown
Vaccinated for COVID?
Yes
No
Unknown
Authorized to work in the US?
Yes
No
Unknown
In accordance with the American's Disability Act (ADA), do you have a disability that would prevent you from performing your job duties?
Yes
No
Unknown
What Facilities do you Currently work at FT/PT?
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