Starkey, Inc. :::

Starkey Inc. Employment Application

Thank you for your interest in Starkey Inc. Please complete the following application and hit the submit button when finished.

Personal information:

Name

Street Address

City

State/Province

Zip/Postal Code

Home phone

Other phone

E-mail

Position Applying For:

How did you learn about us?

Date of availability:

Hours available to work:

Select Preferred Shift:
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.

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?

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

Are you currently enrolled in a KPERS (Kansas Public Employees Retirement System) retirement plan?
Yes No

Are you currently receiving KPERS retirement benefits from another organization?
Yes No

Thank you for your interest in Starkey Inc. You will be contacted to provide your Social Security number and a signature to certify that all statements contained in the application are true, and that you will abide by all regulations and policies at Starkey Inc.


4500 W. Maple • Wichita, KS 67209 • (316) 942-4221 2007 © Starkey Inc. All rights reserved.