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Employer Registration

Please complete the physician staffing request form below, or if you prefer, call us at 877-583-6367. Thank you for considering Nationwide Locum Tenens.


* Required Fields

First Name : *
Last Name : *
Company : *
Address 1: *
Address 2:
City : *
State/Province : Zip Code :
Corporation Affilication:
Phone : ext. *
Fax :
Email : *
Confirm Email : *
Have you worked with Nationwide Locum Tenens before? Yes No
Specialties Needed :
You may select more than one.
For multi-select, press the 'Ctrl' button while selecting
Date needed from : Click Here to Select Date
Date needed to : Click Here to Select Date
Reason for need :
Breif practice description or other comments:

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