Employment Application

First Name

Middle Initial

Last First Name

Street Address

City

State

Zip

Phone

Mailing Address

City

State

Zip

Email Address

Date of Birth

Social Security Number

Driver’s License Number

Position Applied For

Have you ever applied for a position with this company before? Have you ever applied for a position with this company before? Yes No

If yes, when?

Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No

If yes, explain?

Are you a citizen of the United States? Are you a citizen of the United States? Yes No

If no, are you authorized to work in the U.S.? If no, are you authorized to work in the U.S.? Yes No

Do you have both CPR and FIRST AID Do you have both CPR and FIRST AID Yes No

List all restrictions for proper job assignment. (Weight Lift Limit, Back Problems, Vehicle Issues, ect.)

Employment Preference: Employment Preference: Full Time Part Time Temporary Summer

Please indicate a time frame

Check all available shifts Check all available shifts 1st 2nd 3rd

Comment

HIGH SCHOOL

Address

From

To

Diploma

COLLEGE

Address

From

To

Degree

OTHER

Address

From

To

Degree

Reference #1: Full Name

Years Known

Email

Reference #2: Full Name

Years Known

Email

Reference #3: Full Name

Years Known

Email

Company 1

Phone

Job Title

Supervisor

Full Address

Work preformed and reason for leaving

May we contact your previous supervisor for a reference? May we contact your previous supervisor for a reference? Yes No

Company 2

Phone

Job Title

Supervisor

Full Address

Work preformed and reason for leaving

May we contact your previous supervisor for a reference? May we contact your previous supervisor for a reference? Yes No

Company 3

Phone

Job Title

Supervisor

Full Address

Work preformed and reason for leaving

May we contact your previous supervisor for a reference? May we contact your previous supervisor for a reference? Yes No

Military Branch

From

To

Rank at discharge:

Type of discharge:

If other than honorable, explain:

Digital Signature

Date (mm/dd/year)

12 + 8 =

Disclaimer and signature

I certify that the answers given by me in this application are correct to the best of my knowledge I understand that any falsification of this application whether willingly or accidental is grounds for disqualification of employment consideration or dismissal from employment if I am hired. I authorize STARS, Inc. to contact any and all of the references I have listed above to obtain previous employment information or any other pertinent information that they may have. Further I release the above-mentioned references from any and all liability for any damages that may result form information collected by this company. Verification of eligibility to work in the United States must be satisfied for an offer to be made.

*Reference Check Procedure: Must show 5 years history, must contact employers of 6 months or longer and most recent. Must show one known for 5 years, no work references as personal references and must contact 2. Verifications will be shown by green check mark with date and Initial of staff conducting. Issues needing clarified or corrected b potential employees will be highlighted in blue. Applications will be used in training class.

OUR MISSION

S.T.A.R.S. Application

Employment Application

Disclaimer and signature