Facility Information Form
Name of Facility:
Physical Location of Facility:
,
City
State
Zip
Billing Address of Facility:
,
City
State
Zip
FEIN:
E-Mail:
Contact Person
Phone Number
Fax Number
Type of Facility
Hospital
Nursing Home
Home Health
Outpatient
School
Other
Type of Therapist Needed:
PT
PTA
OT
COTA
ST
Number of Therapists Needed:
Date Therapist(s) Needed:
Number of therapists and type of disciplines you currently employ:
Any special skills required for the position:
Additional Comments:
Person completing this form:
Title:
