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TJC Certification
YesNo

Diversity Class (check all that apply)
Minority Business Enterprise (MBE)Woman Business Enterprise (WBE)US Veterans - Veteran Business Enterprise (VBE)Other (please list below)None

Other Diversity Class (only answer if you selected "Other" above)

Type(s) of placement services you offer (check all that apply)
Travel/Local ContractLocum TenensStaff/Perm PlacementPer Diem

Type(s) of staff you provide (check all that apply)
NursingAlliedTherapyPhysiciansAdvanced PracticePharmacyDentalExecutive LeadershipNon-clinical

Area(s) you serve (check all that apply)
NationalNortheastMid AtlanticSouthwestMidwestGreat PlainsSouthwestPacific NorthwestWest Coast

Services requested