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Candidate's Information
Requested by:
Tailored Healthcare Staffing
Medical Staffing Options
Next Travel Nursing
Health Carousel
Partner Network
Requested by email:
Enter candidate's information below.
Candidate's First Name:
*
Candidate's Last Name:
*
Candidate's Mobile Phone Number:
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Candidate's Email Address:
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Facility Information
Please provide information about the healthcare facility and your employment history.
Name of Healthcare Facility:
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Facility Location (City, State):
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Select the title that best describes your role at the facility:
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Staff
Travel
Per Diem
Are you still employed at the above facility?
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Yes
No
Your Profession and Specialty in the above position:
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Start date:
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End date:
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+
End Date:
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Supervisor Information
Please provide contact information and relationship details about your clinical reference.
Select the title that best describes your supervisor's role at the facility:
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Supervisor
Charge Nurse
Unit Manager
Director
MD
CNO
Supervisor's First Name:
*
Supervisor's Last Name:
*
Supervisor's Work Phone:
Supervisor's email address:
*
Confirm email address
*
By tapping "Submit", you authorize Health Carousel to immediately contact the listed reference above via email and/or phone.