Your Name:   

Title:   

Hospital/Facility:  
    
Address:   

City:    State:    AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY  

Zip Code:    

Phone #:     Ext:   

 e-Mail:  

How do you prefer to be contacted: Email  Phone  Either

Facility Type: Acute Care Hospital  Critical Access Hospital 

Long-term Acute Care  Long-term Care  Skilled Nursing 

Other  

Total Beds:      Average Daily Census:    
 

Step Two: POSITION SPECIFICATIONS
 

Position Title:     

Title of the individual position reports to:  

How long vacant: 

Projected assignment start date:   

Projected length of assignment:   

RN Required (Registered Nurse) 

CPHQ Required (Certified Professional in Healthcare Quality) 

Degree:  Select One Degree Not Required Associates Preferred Associates Required Bachelors Preferred Bachelors Required Masters Preferred Masters Required  
              
Add general comments / special instructions / additional information here

Your request will be handled promptly.  A confirmation email will be sent shortly and one of our Account Managers will contact you directly.

Thank you for your valuable time and we look forward to earning your business.
 
Step Three:   Send request to Galileo Search     Start over

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