Staff Requisition Form

Please complete the form below to apply for a Staff Requisition with us.

Name of Facility Making Requisition

Address

Phone Number

Email Address

Requisition Date

Type of Recruitment

Requisition Ordered by

Supervised by

Title of Position

Dept

No. of Vacancies

Position Reporting to

Title

Type of Employment

From

To

Required Date

Compensation Type

Compensation

Frequency

Rate

Key Functions and Duties

Qualification and Qualities

Maximum Work Experience

Opt-In

I, the undersigned, being the immediate supervisor of the staff being procured here, the unit head to whom the supervisor reports to or the facility administrator who oversees the facility authorize New Era Health Care Staffing Services (NEHCSS) to begin the process of procuring the above described clinician, therapist or staff. In the event that this procurement is cancelled due to no fault of NEHCSS, client agree to reimburse NEHCSS reasonable costs incurred in the search and procurement of the said staff.

Requested by

Requested by

Immediate Supervisor (Full Name)

Immediate Supervisor (Signature)

Upload File

With knowledge and approval of Unit Head and /or Administrator.

With knowledge and approval of Unit Head and /or Administrator

Unit Head/Facility Administrator (Full Name)

Phone Number

Email Address