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Request for more information

If you are not currently registered as a travel nurse with FASTAFF, please fill out the form below. If you are currently registered or assigned to a recruiter, please do not re-submit the request form. Call 877-912-9478 to speak to a FASTAFF representative. FASTAFF will keep this basic personal information confidential. We will use it only to contact you about your interest in our company. The fields marked with a red asterisk (*) are required.

*First

*MI

*Last Name

*Mailing Address

Apt/Suite

* City

* State

* Zip code

* Current phone (e.g. 333-444-5555)

Work phone (e.g. 333-444-5555)

Mobile phone (e.g. 333-444-5555)

Fax number (e.g. 333-444-5555)

* Email address

How do you prefer to be contacted?

Current phoneWork phoneMobile phoneEmailU.S. Mail

What is the best time of day to reach you?

* How did you find out about us?

If you were referred by a nurse or other source, please specify here:

Background Information

* Are you a:

RNLPN/LVNOther, please specify

If other, please specify:

*What is your primary area of Specialty:

If Primary Specialty is Other, please specify:

* What state license(s) do you currently hold?(e.g.: CA, NY, WA, FL, etc.)

I have applied with FASTAFF in the last two years

* Please tell us about your recent acute care experience
Less than 1 year1 or more years5 years or more

*Are you available to work within 90 days?
Yes No

If no, when are you available to work?

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