* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Do you have reliable transportation?

Yes   No

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time

* Hourly rate/salary earned at last position.:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
	Yes   No
	Yes   No
	Yes   No

In consideration for my being considered for employment, I agree to conform to the policies and procedures of CareStar. I understand that by accepting this application, CareStar is in no way obligated to offer me employment and that I am not obligated to accept employment if offered. Furthermore, if CareStar employs me, I understand that my employment will be “at will,” which means that CareStar or I may terminate employment at any time with or without cause.

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statement or omission of fact on this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated.

I also understand that any offer of employment is conditioned on pre-employment procedures, my performance on written tests that assess skills and content pertinent to the job, Bureau of Criminal Identification and Investigation (BCII) Criminal Background investigation (including fingerprint impressions), and documentation such as proof of residency and eligibility to work in the United States. I will, upon request, sign all necessary consent forms. I also authorize any current or previous employers, schools or educational institutions, individuals, and representatives of the foregoing, to give any information regarding my employment, qualifications, and character. I hereby expressly release said current or previous employers, schools or educational institutions, individuals, and their representatives from any and all liability for any damage that may result from their issuing or disclosing any information or knowledge to CareStar. I have read and understand the contents of this employment application and am fully able and competent to complete it. I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date: