Starlite Care » Exceptional Care

Please read carefully. This application consist of 17 different sections and will take you approximately 60min or less to complete. You are required to fill all fields to your best knowledge in other to be considered for employment.

This application will allows us to learn about your work experience, skills, and education. We use this job application to compare and contrast applicants and decide which one is best for the job. We require you to submit this application and also upload your resume.

NOTE: This application does not save, so you can't come back to complete it. Once you start you are required to complete it and get a confirmation that your application has been received.
Required check list*
- Thoroughly completed employment application
- Current professional license (Signed), if any
- Current CPR card/First Aid (Signed)
- Employment Eligibility Verification (Form I-9)
- Two employment reference letter (Phone # Included)
- Three personal reference letter (Phone # Included)
- Driver's license/ State issue ID card (Signed)
- Copy of Social Security Card (Bring original signed copy to Interview)
- Two years of experience working in the fiel
- Background Check (A Must)
- Any other information you have for employment

Name*
First Last
Home Phone
Mobile Phone*
Email*
Last 4 SSN*
Last 4 dight of your Social Security Number
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Applied For*

Application for Employment
We consider applicants for all positions without regard to race, color, religion, creed, gender, nationalorigin, age, disability, maritalor veteran status, sexual orientation, or any other legally protected status. Reasonable accommodations maybe made to enable individuals with disabilities to perform the essential functions of the position.
1. Please fully and accurately complete the Application for Employment. Incomplete applications will not be considered. This company will use the information given in the application to verify your previous employment and background.
2. The Application for Employment will be considered in active after 90 days. If you wish to be considered after that time, you must complete a new Application for Employment.
3. Resume will not be accepted in lieu of completed applications, but will be considered supplemental information.
4. If you are hired, proof of eligibility will be required to verify your lawful right to work in the United States.

Part A: Personal Information
Please Fill Out Completely
Name*
Prefix First Last Suffix
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Correspondence Address (If different:)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Telephone*
Work Telephone*
May we contact you at work?*
Date of Birth*
Are you a citizen of the United States?*
Are you eligible to work in the United States?*
Do you have a work permit or a right to work Visa?*
Have you ever been convicted of a misdemeanor or felony?*
Please explain the circumstance of the conviction

Part B: Education and Training
Please Fill Out Completely
High School Name*
High School Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates Graduated*
Did you receive a Diploma?*
Area of Study*
Colleges/Training Schools
Please Fill Out Completely
College/Training School Name*
College/Training School Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates Graduated*
Did you receive a Diploma?*
Area of Study*
Professional trainings/qualifications with dates and levels obtained

PART C: PRESENT AND PAST WORK HISTORY
Please Fill Out Completely

Work History 1
Employer*
Employer's Phone*
Employer's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held & Duties*
Reason for leaving*
Starting salary*
Ending salary*
May we contact this employer?*
Please state reason why?*

Tell us why we shouldn't contact this employer

Work History #2
Employer #2*
Employer's Phone #2*
Employer's Address #2*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held & Duties #2*
Reason for leaving #2*
Starting salary #2*
Ending salary #2*
May we contact this employer? #2*
Please state reason why? #2*

Tell us why we shouldn't contact this employer

Work History #3
Employer #3*
Employer's Phone #3*
Employer's Address #3*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held & Duties #3*
Reason for leaving #3*
Starting salary #3*
Ending salary #3*
May we contact this employer? #3*
Please state reason why? #3*

Tell us why we shouldn't contact this employer

Work History #4
Employer #4*
Employer's Phone #4*
Employer's Address #4*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Held & Duties #4*
Reason for leaving #4*
Starting salary #4*
Ending salary #4*
May we contact this employer? #4*
Please state reason why? #4*

Tell us why we shouldn't contact this employer

PART E: SUPPORTING STATEMENT
Please indicate all relevant experience, skills and work history that relate to the job description of which have applied. All illegible entries will not be considered.

PART F: MEDICAL HISTORY
What absences due to illness have you had from work for the last two years?
Do you have any illness that will present you from performing the duties of the position of which you have applied?*
Please indicate the illness*
Can you lift a weight of 70 pounds?*

PART G: REFERENCES
Please list three character references of which we may contact.
Reference #1
Ref #1 Name
First Last
Ref #1 Relationship
Ref #1 Years of Affiliation
Ref #1 Telephone number
Reference #2
Ref #2 Name
First Last
Ref #2 Relationship
Ref #2 Years of Affiliation
Ref #2 Telephone number
Reference #3
Ref #3 Name
First Last
Ref #3 Relationship
Ref #3 Years of Affiliation
Ref #3 Telephone number
Reference #4
Ref #4 Name
First Last
Ref #4 Relationship
Ref #4 Years of Affiliation
Ref #4 Telephone number

PART H: DECLARATION
By typing your full name in the field below you, hereby certify that all information you field/answered in this application is true and valid to the best of your knowledge. You also understand that misrepresentation of falsification of the information provided above will result in your immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery
Name*
First Last
Date*
MM
DD
YYYY

PROFESSIONAL LICENSE VERIFICATION
Professional license*
Effective Date*
Registry or Certification*
Effective Date*
Out or State Licence*
Is registration or licences Pending?*
Are you currently the subject of a compliant?*
To your knowledge are you currently the subject of a compliant or are you under investigation by any professional licensure or registration body such as a State Attorney Grievance Commission or a State Board of Nursing?
Please Note below all details known to you regarding this compliant or investigation.*
Has your license ever been suspended*
Has your license ever been suspended or revoked or have you otherwise been reprimanded, disciplined or sanctioned by any professional licensure or registration?
Please explain*
Are you currently the subject of any criminal or other charges*
Are you currently the subject of any criminal or other charges that could affect your license or registration to practice in your profession if found meritorious
Please explain*
Is any non-complete, non-solicitation, non-disclosure, or similar agreement applicable to your current activities*
Is any non-complete, non-solicitation, non-disclosure, or similar agreement applicable to your current activities
Attach a copy of the agreement to this application.*
STARLITE CARE, INC. WILL VERIFY ALL NURSING LICENSES THROUGH MARYLAND BOARD OF NURSING (MBON)
Name*
First Last

CONFIDENTIAL AGREEMENT
Please click here to read/print the confidential agreement. You are required to print and sign this document then fax it to 301-444-4444

Please click here
Name
This field is for validation purposes and should be left unchanged.

Employment

Application For Employment

Step 1 of 17

Application for Employment

Part A: Personal Information

Part B: Education and Training

Colleges/Training Schools

PART C: PRESENT AND PAST WORK HISTORY

Work History 1

Work History #2

Work History #3

Work History #4

PART E: SUPPORTING STATEMENT

PART F: MEDICAL HISTORY

PART G: REFERENCES

Reference #1

Reference #2

Reference #3

Reference #4

PART H: DECLARATION

PROFESSIONAL LICENSE VERIFICATION

STARLITE CARE, INC. WILL VERIFY ALL NURSING LICENSES THROUGH MARYLAND BOARD OF NURSING (MBON)

CONFIDENTIAL AGREEMENT

Please click here to read/print the confidential agreement. You are required to print and sign this document then fax it to 301-444-4444

Please click here

Day	Open	Close
Sunday	Closed
Monday	9:00	5:00
Tuesday	9:00	5:00
Wednesday	9:00	5:00
Thursday	9:00	6:00
Friday	9:00	5:00
Saturday	10:00	5:00