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Staff Request Form

Allied Nurse Staffing; Staff Request Form

Part 1: Contact Information

*Indicates a required field

________________________________________

*Facility:___________________________________

*Your Name:_________________________________

Department:_________________________________

Title:______________________________________

Address 1:___________________________________

Address 2:__________________________________

City:________

State:_______

*Zip:_______

*Phone:___________________________________

Fax:______________________________________

*Email Address:______________________________

Have you ever utilized services from Allied Nurse Staffing in the past?

 Yes        No____


Part 2: Service Request

________________________________________

Please indicate job/ profession:

Hospital 0 Nursing Home 0 

School 0 Doctor's Office 0 

Others 0 

I am in need of coverage for the following dates:

Beginning__________ Through_________

Travel O

Local Contract O

Temporary to Hire O

Direct Hire O

Education Staffing Services O

Coverage O

Other Information:

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Get in Touch 

Contact Allied Nurse Staffing Agency to find out more about our services. You may also send your questions and messages
using the form on this page.

Service Area 

Proudly Serving the Entire State of Maryland

Business Hours 

Monday to Friday:
 7:00 AM – 7:00 PM

After Business Hours Services 

Call: 443-418-6056

Contact Information 

Allied Nurse Staffing Agency

4707 B Hartford Road

Baltimore, Maryland 21214

Phone: (443) 418-6056 | (443) 754-3017

Email: [email protected] 

Inquiry Form 


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