Application for Employment (PDF)

ECHO Community Health Care, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration without discrimination because of sex, race, color, religion, creed, national origin, or the presence of disabilities.
Position applying for:*
Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone*
Email*
example@example.com
Are you Age 18 or Older?*

YesNo
Are you a U.S. Citizen?*

YesNo
Do you have a current & valid Driver's License?*

YesNo
Have you ever been convicted of a crime that has not been expunged by a court of law?*

YesNo
If Yes, Please Explain
High School Name*
High School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
College Or University Name
College or University Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
College Degree Completed
Please list the degree
Graduate School Name
Graduate School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Graduate Degree Completed
Please list the degree
Trade or Technical School Name
Trade or Technical School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Degree or Certificate Completed
Please list the degree or certificate
Professional Licensure or Certification (complete as appropriate)
Type of License or Registration, ID Number, Issue Date, Expiration Date, State
Technical and Professional Job Related Memberships
EMPLOYMENT

List all employment, starting with present or most recent position.
Present Or Last Employer*
Start Date*

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer Phone*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name*
May we contact them?*

YesNo
Starting Salary
Last Salary
Reason for leaving?*
Next Previous Employer
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer Phone
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
May we contact them?

YesNo
Start Date of Employment

MonthDayYear
Date
End Date of Employment

MonthDayYear
Date
Job Title
Nature Of Work And Responsibilities
Starting Salary
Last Salary
Reason For Leaving
Next Previous Employer
Employer Phone
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
May we contact them?

YesNo
Start Date of Employment

MonthDayYear
Date
End Date of Employment

MonthDayYear
Date
Job Title
Nature Of Work And Responsibilities
Starting Salary
Last Salary
Reason For Leaving
Next Previous Employer
Employer Phone
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
May we contact them?

YesNo
Job Title
Start Date of Employment

MonthDayYear
Date
End Date of Employment

MonthDayYear
Date
Nature of Work And Responsibilities
Starting Salary
Last Salary
Reason for leaving?
Please explain any gaps in your employment history:
Do you have any relatives employed at ECHO?*

YesNo
If Yes, List Names And Relationships
Were you referred to us by a current ECHO employee?*

YesNo
If Yes, please provide the employee's name:
Voluntary Information

Invitation To Self Identify. Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin.This employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, this employer invites applicants and employees to voluntarily self-identify their race/ethnicity and gender.Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
What is your gender?

FemaleMaleI do not wish to answer
What is your Ethnicity?

White (not Hispanic or Latino)Hispanic or LatinoBlack or African American (not Hispanic or Latino)Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)I do not wish to answer
Voluntary Self-Identification of Disability

Why are you being asked? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this part is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.Disabilities include, but are not limited to: Blindness, Deafness, Cancer, Diabetes, Epilepsy, Autism, Cerebral Palsy, HIV/AIDS, Schizophrenia, Muscular Dystrophy, Bipolar Disorder, Major Depression, Multiple Sclerosis, Missing Limbs or Partially Missing Limbs, Post-Traumatic Stress Disorder, Obsessive Compulsive Disorder, Impairments Requiring The Use Of A Wheelchair, Intellectual Disability (Previously Called Mental Retardation)
Please select one:

YES, I have a disability (or previously had a disability)NO, I do not have a disability.I wish not to answer
NOTICE: READ CAREFULLY AND SIGN

I voluntarily authorize ECHO Community Health Care (ECHC) to make a thorough pre-employment investigation. I hereby authorize former and present employers, except as otherwise indicated on this application, and others to provide or verify any information they have regarding me or my employment and release them from any liability for furnishing such information to ECHC. I understand that employment is contingent upon satisfactory investigation of references. All information in this application and employment related documents are true and complete. I understand that if I am employed, false statements on this application and employment related documents shall be considered sufficient cause for dismissal. Upon an offer of employment, I agree to have a medical evaluation and understand that my employment is contingent upon passing the evaluation. I agree to take such future medical evaluation as may be required by ECHC. I understand that my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of the ECHC Board of Directors. If employed, I agree to abide by the policies, procedures, and rules of ECHC. I further agree to protect the confidentiality and privacy of any information regarding ECHC patients.
Please Type Name as your Signature*

First NameLast Name
DATE OF SIGNATURE*

MonthDayYear
Date
Should be Empty:

EMPLOYMENT

Voluntary Information

Voluntary Self-Identification of Disability

NOTICE: READ CAREFULLY AND SIGN