APPLICATION FOR EMPLOYMENT                                 Date:____________________________________                                                 

Position applied for:___________________________________          Date of availability:__________________________ 

 

4500 W. Maple, P.O. Box 9290

Wichita, KS 67209

(316) 942-4221
 
How did you learn about us?______________________         Hours available to work:     Full Time              Part Time

                                                                                                                                                                7 On/7 Off*            1st            2nd          3rd

*Majority of 7 on/7 off positions will be required to work 7 consecutive days with overnight stay and then off 7 consecutive days.

 

Name ________________________________________________________________________________ Social Security # _______________________________

            First                                                                         Middle                                                                      Last

 

Address ____________________________________________________________________________________________________________________________

               Street                                                                                                    City                                                                          State                                                        Zip

 

Phone _______________________________________ Cell Phone ___________________________________ Email ____________________________________

 

Driver’s License # _______________________________ State _______________ Expires __________________________

Are you 18 years or older?  _____ Yes  _____ No          If hired, can you provide proof that you are eligible to work in the United States?  _____ Yes  _____ No

Have you ever been convicted of a felony? Yes ____ No ____  If yes, please provide the date, place of the conviction, crime convicted of and the sentence imposed:____________________________________________________________________________________________________________________________

(CONVICTIONS ARE EVALUATED FOR EACH POSITION AND ARE NOT NECESSARILY DISQUALIFYING)

 

Education: Circle the highest grade completed                           Name of School                                 Degree                           Credit Hours                     Major

High School         9        10        11        12     GED

 

 

 

 

College                           1         2         3         4

 

 

 

 

Graduate School            1         2         3

 

 

 

 

Business, Vocational or other

 

 

 

 

Are you currently attending school?        Yes _____ No _____

 

Work Experience: Start with the most recent employer

            Employer                                      City/State                                  Dates                           Position                                                Salary                                     Reason for Leaving

                                                                                                                     From        To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently employed?             _____ Yes             _____ No              If yes, may we contact your present employer?             _____ Yes                _____ No

                Whom should we contact?  Name ________________________________________________  Phone___________________________________________

Have you ever been employed at Starkey?    _____ Yes             _____ No                              If yes, when? ________________________________________________

                Your position: _________________________________________ Under what name were you employed? ________________________________________

Have you had any experience working with people with disabilities?      _____ Yes             _____ No              If yes, please describe: ___________________________

___________________________________________________________________________________________________________________________________

Do you know sign language?           _____ Yes             _____ No                              If yes, state type:__________________________________________________________

PROFESSIONAL CERTIFICATION/LICENSES (ie. CNA, CPR, First Aid)

Type                                                                                                                       Organization /Agency or State                                                                          Expiration Date

 

 

 

 

 

 

 

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

Name                                                            Company                                 Work Phone                     Home/Cell Phone           Email                                        Job Title                      Years Acquainted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently enrolled in a KPERS Retirement Plan?   Yes ______   No ______

Have you reviewed the Realistic Job Preview that is required for consideration of employment at Starkey, Inc.?  Yes______     No ______

 

PLEASE READ BEFORE SIGNING

If you have any questions regarding these statements, please ask them of an employment interviewer before signing.

 

 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.

 

I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS.

 

 

SIGNATURE OF APPLICANT____________________________________________________________ DATE _________________________________________