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New Staffing Providers : Request Affiliation with AHSA

If you are interested in potentially becoming an approved staffing provider to AHSA and its growing list of member facilities, please feel free to complete the form below. Please be sure to describe the types of services your firm provides in the “Company BIO” section below. If determined eligible, we will add your contact information to our database to receive more information as future AHSA contracting opportunities materialize.

Please fill out and submit the form below to begin the staffing provider registration process.

NOTE: If you are already an approved, contracted staffing provider to AHSA wishing to request a user account, please go to the Current Vendor/Member: Account Request Form. Please note that current contract status will be verified before processing.

* required

E-Mail Address *

First Name *

Last Name *

Company *

Company Address *

City *

State *

Zip *

Phone *


How did you hear about AHSA? *

Company Bio *

Terms and Conditions

I agree to the above Terms and Conditions *

Please type the word from the image in this field.