Reimbursement Form

Please ensure that all receipts and other necessary items are attached in order for reimbursement to be processed. If unable to attach here, please send to your Compliance Coordinator , Recruiter, email to reimbursement@ronarastaffing .com or fax to 661-505-7045 Thank you!!!

RN/Employee Name *

Facility Name *

Assignment Duration (From)*

Assignment Duration (To)*

Is this your first assignment with Ronara Staffing Solutions ? *

Yes

No

Licensing Reimbursements
RN License Reimbursement
RN License Application
Fingerprinting
Nursys/Other Verification

Licensing Reimbursement Total

Certification Reimbursement Total

Medical Reimbursement Total

Other
Annual Scrubs ($50/yr)
ID Photo (when required by facility)
Professional Liability Insurance ($100/yr)
Other Item Required by Facility

Other Items Reimbursement Total

Reimbursement Grand Total
$0.00 Calculate

Licensing Receipts

Certication Receipts

Medical Receipts

Other Receipts

Signature *