Information Request - Staffing   Please fill out form as completely as possible. All information provided is kept in strict confidence. Facility Name: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Contact Name: Title: Phone and Ext: Fax: Email Address: Position Needed: RN LPN CNA RRT CRTT PT OT Other Specify Other Position: Duration of Need: Six Weeks Eight Weeks Twelve Weeks Sixteen Weeks Permanent Other Specify Other Duration: Shift Needed: Days Nights Evenings Other Specify Shift Needed: Start Date: Additional Information:

PEL appreciates the opportunity to help solve your staffing problems.  A representative will contact you upon receipt of this information.