STAR MULTI CARE HOLDING CORP. & SUBSIDIARIES EMPLOYMENT APPLICATION

EQUAL EMPLOYMENT OPPORTUNITY

Star Multi Care Holding Corp. & Subsidiaries is an Equal Opportunity Employer. We do not discriminate against qualified applicants based upon any protected group status, including but not limited to race, color, creed, religion, gender, national origin, ancestry, age, marital status, military or veteran status, sexual orientation, physical or mental disability or medical condition as defined by applicable equal opportunity laws.

DISCLAIMERS

We are glad you are interested in joining Star Multi Care Holding Corp. & Subsidiaries’ team. Please read the following statements carefully before you agree and submit this application.

Star Multi Care & Subsidiaries, in considering your application for employment, may verify the information set forth on this application and obtain additional information related to your background.

Star Multi Care & Subsidiaries offers reasonable accommodations in the hiring and employment process for individuals with disabilities. If you need assistance in the application or hiring process to accommodate a disability, you may request an accommodation at any time.

NOTE TO CANDIDATE

This application will be considered active for 60 days. If you have not been hired within 60 days of submitting this application and you wish to be considered for employment, you must complete a new application

PERSONAL INFORMATION (Incomplete information could disqualify you from further consideration.)

First Name *

Last Name *

Email *

Phone *

Street Address *

City *

State *

Country *

Postal code *

Are you at least 18 years or older? *

Yes

No

Are you legally authorized to work in the U.S.? *

Yes

No

If hired, can you submit documentation verifying your identity and your legal right to work in the U.S. within 3 business days of when you begin work for pay? *

Yes

No

Have you ever worked or attended school under another name? *

Yes

No

If so, under what name?

Excluding minor traffic offenses, have you ever been convicted of a crime? *

Yes

No

*A “yes” answer will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.

Have you ever been terminated from employment or asked to resign by an employer? *

Yes

No

If yes, please provide company name and details:

POSITION/AVAILABILITY

Position(s) Applied For: *

Available Start Date: *

Hourly Rate/Salary Desired *

Are you currently employed? *

If so, may we contact your present employer?

Do you prefer Full Time or Part Time? *

Full Time

Part Time

What is your means of transportation to work? *

Day/Hours Available:

Monday: *

Tuesday: *

Wednesday: *

Thursday: *

Friday: *

Saturday: *

Sunday *

Total hours per week desired: *

Are you available to work: *

Weekends

Holidays

Nights

Are you available to work overtime? *

Yes

No

EDUCATION

Have you served in the US Military? *

Yes

No

If yes, please describe any relevant skills acquired while serving in the US Military.

LICENSES/CERTIFICATIONS

Do you have any Licenses, Certifications or other credentials to work in the position for which you have applied? *

Yes

No

If yes, please list all credentials you possess:

Professional License, License No., Exp Date, Verification:

Para-Professional Certification

HHA

PCA

CNA

School/Training Program & Verification:

EMPLOYMENT HISTORY

Please list all previous employment, beginning with the most recent. If you need more room, you may attach additional sheets of paper. Incomplete information could disqualify you from further consideration.

Former or Current Employer #1 Company Name *

Former Employer #1 Address *

Former Employer #1 Title/Position Held *

Former Employer #1 End Date *

May We Contact Former Employer #1? *

Former or Current Employer #1 Supervisor's Name & Title: *

Former or Current Employer #1 Reason for Leaving: *

Have you previously worked for Star Multi Care Holding Corp. & Subsidiaries? *

Yes

No

If so, from when to when?

Reason(s) for leaving:

References:

Reference Name 1: *

Reference Phone 1: *

Reference Address 1: *

Reference Relationship 1: *

Reference Name 2: *

Reference Phone 2: *

Reference Address 2: *

Reference Relationship 2: *

ACKNOWLEDGEMENT AND AUTHORIZATION

I certify that the information contained in this application is true and complete. I attest to the fact that the answers given by me are correct to the best of my knowledge and ability. I certify that I have not knowingly withheld any information that might affect my chances of hiring. I understand that any false information or omission (including any misstatement) on this application or on any document used to secure this employment can be grounds for rejection of my application or, if I am employed by Star Multi Care Holding Corp. and Subsidiaries, can be grounds for my immediate termination from Star Multi Care Holding Corp. and Subsidiaries.

I authorize Star Multi Care Holding Corp. and Subsidiaries to check and verify any and all information listed above, including but not limited to my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

I understand that this application is not a contract, offer or promise of employment and that if hired, I will be an at-will employee. As such, I will be able to resign at any time for any reason. Likewise, Star Multi Care Holding Corp. and Subsidiaries can terminate my employment at any time with or without cause, unless otherwise required by law. I further understand that no one other than Star Multi Care Holding Corp. and Subsidiaries has the authority to enter into an employment contract or agreement with me and that my at-will employment can be changed only by a written agreement.

Candidate's Signature *

Clear

Today's Date *