24 Hour Staffing Solutions Inc.  Nursing Registry  415-648-6091    Fax: 415-648-8394
Name: ______________________   Title: _______   Signature:  ____________________
         Please fill out all the appropriate boxes and have an authorized person sign before leaving the facilities.
       FACILITY   Date Unit Time In Lunch in Lunch out Time out Reg. Hrs OT Facility's Signature / Title
                     
                     
                     
                     
                     
Facility's Signature ___________________________________         Title ______________________        
                     
                     
                     
            I agree to terms Net Upon Receipt and to pay interest on unpaid over days at the rate of 21% annum
            together with all collection and litigation cost, plus interest and resonable attorney fees.  I recognize
            the rights of 24 Hour Staffing Solutions as agent and agree not to employ directly in any capacity 
            the person name hereon without first providing 24 Hour Staffing Solutions with at least 90 working 
            days written notice following the conclusion of this assignment.  I certify that the hours shown above are 
            correct and that the contractor performed satisfactorily.
                                             White -  24 Hour Staffing Solutions Copy              Canary - Nurse Copy   
24 Hour Staffing Solutions Inc.  Nursing Registry  415-648-6091    Fax: 415-648-8394
Name: ______________________   Title: _______   Signature:  ____________________
         Please fill out all the appropriate boxes and have an authorized person sign before leaving the facilities.
       FACILITY   Date Unit Time In Lunch in Lunch out Time out Reg. Hrs OT Facility's Signature / Title
                     
                     
                     
                     
                     
Facility's Signature ___________________________________         Title ______________________        
                     
                     
                     
            I agree to terms Net Upon Receipt and to pay interest on unpaid over days at the rate of 21% annum
            together with all collection and litigation cost, plus interest and resonable attorney fees.  I recognize
            the rights of 24 Hour Staffing Solutions as agent and agree not to employ directly in any capacity 
            the person name hereon without first providing 24 Hour Staffing Solutions with at least 90 working 
            days written notice following the conclusion of this assignment.  I certify that the hours shown above are 
            correct and that the contractor performed satisfactorily.
                                             White -  24 Hour Staffing Solutions Copy              Canary - Nurse Copy