Thank you for considering Prokontract as your trusted partner in acquiring temporary staff for your esteemed facility. We are excited to assist you in meeting your staffing needs and delivering exceptional care. To get started, please provide us with the following information:

Facility Application

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1. Facility Information: - What is Your Facility Name?: *

Facility Type (Hospital, Nursing Home, etc.)?: *

Facility Location / Address?: *

Contact Person?: *

First

Last

Contact Email?: *

Contact Phone Number?: *

2. Staffing Requirements: - Job Positions Needed?:

Number of Staff Required?:

Preferred Start Date?:

Duration of Staffing Need?:

Shifts (Day, Night, or Rotating)?:

Special Skills or Certifications Required?:

3. Facility Preferences: - Preferred Staffing Agency Contract Length:

Current Rates For Each Staffing Category (i.e. RN =$x):

Preferred Payment Terms:

Additional Requirements or Preferences:

4. Facility Background: - Briefly describe your facility and its mission:

Highlight any specific challenges or unique aspects of your facility:

Please Acknowledge You Read This Part by Typing Yes: By completing this intake form, you are taking the first step towards enhancing your facility's staffing capabilities and ensuring exceptional care for your patients. Our dedicated team at Prokontract will review your information and promptly reach out to discuss your requirements in detail. Together, we will design a tailored staffing solution that meets your needs and exceeds your expectations. *

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