*Name

*Street Address

*City, State, Zip

*Position Applying For

*Home Telephone

*Cellular Phone

Beeper/Pager

*Email Address

Other

Work History

*Contact My Present Employer for Reference Yes No

*Current or Last Employer

*Street Address

*City, State, Zip

*Phone

*Salary

*Dates Worked
from date - to date

Reason for Leaving

Supervisor

Job Title

Duties

Named Used While Employed

*Were You Ever Convicted of a Crime? Yes No

If yes, please explain
Criminal conviction(s) will not automatically disqualify an applicant from employment with Eagle Medical Staffing, Inc.

Education

*Name of High School

*Highest Grade Completed

Street Address

City, State, Zip

Name of College or Nursing School

Street Address

City, State, Zip

RN or LPN Reg No.

Name Used While Attending

Degree/Course/Certificate

Date Receive

State

References - not family related

*Name

*Phone

Street Address

City, State, Zip

Relationship

Years Known

*Name

*Phone

Street Address

City, State, Zip

Relationship

Years Known

Please Read and Accept Below

I hereby authorize Eagle Medical Staffing and also authorize and request each former employer and person, firm or corporation given as a reference to answer all questions that may be asked and give all information that may be sought in connection with this application specifically concerning my work, skill or my professional action in any transaction. My employment with Eagle Medical Staffing will not begin until such references are received.

I agree, in consideration of your employing me that I will not seek or accept employment from any client of Eagle Medical Staffing without first obtaining permission from Eagle Medical Staffing and I agree to remain on the Eagle Medical Staffing payroll for an additional 350 hours after permission has been granted. I understand that if I am in violation of this agreement, I am subject to legal action and monetary damages.

I understand that this employment application is not a contract and that if hired; my employment with Eagle Medical Staffing can be terminated with or without cause, and with or without notice, at any time, at the option of Eagle Medical Staffing. I also understand that any and all benefits received pursuant to employment with Eagle Medical Staffing may be changed or eliminated at will without prior notice.

I consent to having a background check done on my history, including a social security number verification, and I understand that my employment might hinge on this check, including termination if after I am hired, Eagle Medical Staffing acquires inf ormation that precluded my hire.

I authorize Eagle Medical Staffing to copy and forward my personnel file contents, including Medical records, Drug Screen, and/or criminal background check to any and all agencies that require this of Eagle Medical Staffing. I hereby certify that all of the above information is true and correct. I understand that any misrepresentation or false information given on this application will result in rejection or termination of employment.

*Yes, I Agree

*Date

*Required