Submit your open positions to Capitol Medical, Inc. online. If you prefer to relay this information personally, please call (800) 576-6348. If you send this information via the Internet, a Recruiter will call you to confirm our receipt and will then follow up regarding potential candidates. Filling out this form does not commit you in any way to accept the assignment coverage or candidate we offer.

Client Information
Hospital/Facility Name:
Street Address: (Line 1)
Street Address: (Line 2)
City, State, Zip	WV AL AK AR AZ CA CO CT DE DC FL GA GU HI ID IL IA IN 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
Phone:
Fax:
Contact Information
Name:
Title:
Phone:
Fax:
Your Position:
Your Email:
Assignment Information
Discipline:
Unit:
Number needed:
Start Date:
Assignment length:	8 weeks   13 weeks  Other:
Description of the unit and typical patient diagnoses:
Description of Facility:
Form validation: Please enter only the numbers colored in GREEN above: