EHCS Application

Employment Application
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Are you a U.S. Citizen or otherwise authorized to work in the U.S.?

YesNo
All positions at Eclipse Healthcare Staffing require successful completion of a pre-employment drug screen and background check. Do you anticipate any issues with this requirement??

YesNo
Employment Desired:
Position Applying For
Preferred Employment Type
Date You Can Start

MonthDayYear
Date
Salary Desired ($)
Have You applied here before?

YesNo
Education:
High School
Name of High School Attended
Number of Years Attended
Graduated?

YesNo
College
Name of College/University Attended
Number of Years Attended
Area of Study/Degree
Graduated?

YesNo
Graduate School
Name of Graduate School Attended
Number of Years Attended
Area of Study/Degree
Graduated?

YesNo
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Area of Study/Degree
Graduated?

YesNo
Skills/Qualifications:
Skills
List any relevant skills
Qualifications
List any relevant certifications or qualifications
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Position
Current Salary ($)
Reason for Leaving?
Start Date

MonthDayYear
Date
May We Contact?

YesNo
Previous Employment:
Previous Employer
Name of Previous Employer
Position
Previous Salary ($)
Reason for Leaving?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Previous Employer
Name of Previous Employer
Position
Previous Salary ($)
Reason for Leaving?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
References:
Reference 1
Name of Reference
Relationship
Years Acquainted
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference 2
Name of Reference
Relationship
Years Acquainted
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference 3
Name of Reference
Relationship
Years Acquainted
Email
example@example.com
Phone Number
Please enter a valid phone number.
Cover Letter & Resume (Optional):
Cover Letter

Cancelof
Resume

Cancelof
Send Application:
By clicking the 'Submit' button below, I certify that the information provided in this application is true and complete. I understand that falsification, omissions, or misrepresentations may lead to rejection of my application or termination of employment if hired. I also acknowledge that employment, if offered, is 'at-will' in Texas, meaning either party can terminate the employment relationship at any time, with or without cause or notice, subject to applicable law.
Date

MonthDayYear
Date
Signature

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Employment Application

Personal Information:

Employment Desired:

Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

References:

Cover Letter & Resume (Optional):

Send Application: