Screening Packet

Screening Packet
Main Office:

3080 W. Washington St., Suite B. P.O. Box 976, Stephenville, TX 76401
Offices Located In:

Cleburne, Decatur, and Stephenville
Which STAR Council Location are you interested in? *
Contact Numbers:

Toll Free: (800) 375-1395, Fax (254) 965-7416

Do you have Private Medical Insurance? *

Yes - Upload a copy through the "Required Documents Upload" link on our website. No
Primary subscriber:
Primary subscriber address:
Primary subscriber DOB:
Primary subscriber employer:
Do you have a Texas Drivers License or photo ID? *

Yes - Upload a copy through the "Required Documents Upload" link on our website. No
Are you currently employed? - Upload a copy through the "Required Documents Upload" link on our website. *

Yes No -- Letter statement required by the person covering your bills.
Is your spouse currently employed? *

Yes - Upload a copy through the "Required Documents Upload" link on our website. No

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Client Profile Information