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Job Application
Thank you for your interest in Starkey Inc.  Please complete the following application and hit the submit button when finished.
Personal information:
Full Name* 

Street Address* 

City* 

State/Province* 

Zip/Postal Code* 

Primary Phone* 

Alternative Phone 

E-mail* 

* - denotes required field
Position Applying For:

How did you learn about us?

Date of availability:

Hours available to work:

Select Available Shifts:
note: majority of 7 on/7 off positions will be required to work
7 consecutive days with overnight stay and then off 7 consecutive days.





Please select each shift you are available.
Driver's License Number:

State:

Expiration date:

Have you been a licensed driver for 3 or more years?

Are you 18 years or older?

If hired, can you provide proof that you are eligible to work in the United States?

Have you ever been convicted of a felony?

If yes, please provide the date, place of conviction, crime and sentence imposed.
note: convictions are evaluated for each position and are not necessarily disqualifying)

Have you received a high school diploma or GED?

If yes, name school:

Select Highest grade Completed:


COLLEGE / UNIVERSITY:
Level: 

Name of school: 

Degree: 


GRADUATE SCHOOL:
Level: 

Name of school: 

Degree: 


OTHER EDUCATION COMPLETED:
Name of school: 

Degree: 

Are you currently attending school?

If yes, are your classes all online?

Prior Work Experience (please start with most recent employer) :
------------------ EMPLOYER #1: ------------------
Name of supervisor 

Company 

Position held 

Address 

City 

State/Province 

Zip/Postal Code 

Phone number 

Dates employed there 

Salary 

Reason for leaving 


------------------ EMPLOYER #2: ------------------
Name of supervisor 

Company 

Position held 

Address  

City 

State/Province 

Zip/Postal Code 

Phone number 

Dates employed there 

Salary 

Reason for leaving 


------------------ EMPLOYER #3: ------------------
Name of supervisor 

Company 

Position held 

Address 

City 

State/Province 

Zip/Postal Code 

Phone number 

Dates employed there 

Salary 

Reason for leaving 


Are you currently employed?
 Yes No

If yes, may we contact your current employer?
 Yes No

Whom should we contact?
Name 

Title 

Phone number 


Have you ever been employed at Starkey?
 Yes No

If yes, tell when and what position you held (and the name you had when employed).

Have you had any experience working with people who have disabilities?
 Yes No

If yes, please describe:

Do you know sign language?
 Yes No

If yes, state what type.

Professional certifications/licenses (i.e. CNA, CPR, First Aid):
Type 

Organization/Agency or State 

Expiration Date 



REFERENCES: List the names of three supervisors from current or previous employers.

------------------ REFERENCE #1: ------------------
Name 

Company 

Work phone 

Home/cell phone 

E-mail 

Job title 

Years acquainted 


------------------ REFERENCE #2: ------------------
Name 

Company 

Work phone 

Home/cell phone 

E-mail 

Job title 

Years acquainted 


------------------ REFERENCE #3: ------------------
Name 

Company 

Work phone 

Home/cell phone 

E-mail 

Job title 

Years acquainted 


I certify that the information in this application is complete and correct to the best of my knowledge and I understand that Starkey, Inc., shall not be liable in any respect if my employment is terminated because of false statements, answers or omissions made by me on this application. I authorize any education institution and my current and former employers to provide any information they may have concerning me in their records. I hereby release them, their employees, and Starkey, Inc., from all liability for any damage whatsoever for providing and obtaining same. I understand that the extension of all job offers is conditional upon successful completion of a post-offer drug screen and tuberculosis (TB) test. I further understand that failure to pass or submit to a drug screen/TB test will conclude all consideration for employment for a period of 12 months. Additionally, I authorize Starkey, Inc. to conduct required background checks to include: motor vehicle report, criminal background, Kansas Department of Health & Environment, SRS-Adult Protective Services and SRS-Children and Family Services. I understand that as a condition of employment, I will be required to show identification that proves my legal right to work in the United States.
 Should I accept a position with Starkey, Inc., I agree to conform to the policies and procedures of the organization. I understand that employment is "at will" and that Starkey, Inc, and its employees have a right to freely enter into the employment relationship, as well as sever the relationship at any time for any reason. I further understand that my supervisor, any management representative or employee of Starkey, Inc., is not authorized to enter into any agreement of employment for a stated duration to vary the "at will" status of my relationship.
 TYPING MY FULL NAME AND DATE BELOW ACKNOWLEDGES THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS

Type Your Full Name* 


Type Today's Date (month day, year)* 



Equal Employment Opportunity Questionnaire

Starkey, Inc. is requesting the following information from all job applicants in order to evaluate the results of its job recruitment efforts and to maintain up to date records. This form will be immediately separated from your application and will have no bearing on the hiring process.

Your voluntary participation will be appreciated.

Select option for description.
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
A person having origins in any of the black racial groups in Africa.
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
A person who identifies with more than one of the above choices.

Thank you for your assistance!

zip code:

 

Starkey's programs are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), which reviews health and human services.
Starkey, Inc., founded in 1930, is the oldest community-based nonprofit in Sedgwick County, Kansas, serving individuals with intellectual disabilities. Through its business services, employment, recycling, residential, life enrichment and case management programs, Starkey creates possibility in the lives of more than 450 people with disabilities.
Proudly affiliated with
4500 W Maple | Wichita, KS 67209 | 316.942.4221
main office: 8 am to 4:30 pm Monday-Friday
Interactive Partner: Howerton+White