Employment Application Form

PERSONAL INFORMATION

First Name *

Middle Initial *

Last Name *

Social Security Number *

Email *

Address (Include #, Street) *

City *

State *

Zip Code *

Home Phone

Mobile Phone *

Are you 18 years or older? *

Yes

No

Are you a citizen of the United States of America? *

Yes

No

New Option

If no (Alien Registration Number):

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DESIRED EMPLOYMENT

Have you completed formal (120 hr) Nurse's Aide Training? *

Yes

No

Positions Applying For *

Companion

Driver/Transportation

Home Health Aide

Nurse

Do you have a current C.N.A. license? *

Yes

No

Date You can Start *

Salary Desired *

How did you hear about our open position?

Who referred you to Generation Solutions? (please specify)

SERVICE RECORD

Branch of Service:

Years of Service:

Rank:

Discharge:

Honorable

Dishonorable

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EMPLOYMENT HISTORY

Have you ever applied to Generation Solutions? *

Yes

No

If yes where and when?

Have you ever worked for Generation Solutions? *

Yes

No

If yes where and when?

Reason for leaving your employment with Generation Solutions?

Other names used during your employment, education, or military service:

Are you currently employed? *

Yes

No

May we inquire of your present employer? *

Yes

No

Not employed

Most Recent Employer

Company (Most Recent Employer) *

Job Title *

Address *

Phone Number *

Name of Supervisor/Title *

Start Date *

Leave Date *

Starting Salary *

Final Salary *

Description of Work *

Reason for Leaving *

Previous Employer

Company (Previous Employer 1) *

Job Title *

Address *

Phone Number *

Name of Supervisor/Title *

Start Date *

Leave Date *

Starting Salary *

Final Salary *

Description of Work *

Reason for Leaving *

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Click to Add More Previous Employers

Previous Employer

Company (Previous Employer 2)

Job Title

Address

Phone Number

Name of Supervisor/Title

Start Date

Leave Date

Starting Salary

Final Salary

Description of Work

Reason for Leaving

Previous Employer

Company (Previous Employer 3)

Job Title

Address

Phone Number

Name of Supervisor/Title

Start Date

Leave Date

Starting Salary

Final Salary

Description of Work

Reason for Leaving

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PERSONAL REFERNCES

Please give the names of three persons to whom you are not related, whom you have known at least three years. Do not duplicate business references.

References 1

Name (Personal Refernce 1) *

Phone Number *

Years Acquainted *

Address

References 2

Name (Personal Refernce 2) *

Phone Number *

Years Acquainted *

Address

References 3

Name (Personal Refernce 3) *

Phone Number *

Years Acquainted *

Address

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Please list any license, certification, or registration earned relevant to the position for which you are applying.

License/Certification/Registration One

License/Certification/Registration

State

Number

Expiration Date

License/Certification/Registration Two

License/Certification/Registration

State

Number

Expiration Date

If you do not have a required license, have you applied?

Yes

No

Scheduled exam date:

If not licensed in this state, have you applied for reciprocity?

Yes

No

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DISCLOSURE STATEMENT

Have you been convicted, or are you subject to pending charges of a felony or an offense involving drugs/ narcotics, theft, financial dishonesty, inflicting bodily injury, or the abuse of aged/ incapacitated adults? *

Yes

No

Have you ever been excluded from federally funded programs, or are you currently the focus of an investigation that could result in exclusion from federally funded programs? *

Yes

No

If yes to either of the above questions, explain fully:

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CONDITIONS OF EMPLOYMENT

If hired, your offer of employment is contingent upon a satisfactory drug test result and criminal background check. Proof of your identity and employment eligibility in the United States must be established by appropriate documentation at the time you begin work.

Generation Solutions, Inc. is an equal opportunity employer and does not discriminate against applicants or employees on the basis of sex, race, color, religion, national origin, disability, citizenship, ancestry, age, marital status, genetic information, physical or mental disability, or past, present, of future service in the Uniformed Services of the U.S., or any other legally protected status. Generation Solutions operates under an Employment at Will Policy. Employment by Generation Solutions does not confer any contractual right, either expressed or implied, to remain in Generation Solutions’ employ; nor does it guarantee any fixed terms and conditions of employment. Employment is not for any specific time and may be terminated at will, with or without cause, and without prior notice

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AVAILABILITY

Please select your weekend availability. *

Every Saturday

Every Sunday

Every other Saturday & Sunday

Not available on weekends

Please indicate the number of hours you desire to work each week:

Do you have commitments to another employer, which may affect your availability? *

Yes

No

If yes, please specify:

Do you have a current driver's license? *

Yes

No

Do you have an automobile to drive to and from work? *

Yes

No

If no, how will you commute to and from work?

Comments regarding availability to work:

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AUTHORIZATION

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release Generation Solutions from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of Generation Solutions has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is signed by an authorized company representative.

I agree not to provide private services to any client of the Generation Solutions office for which I am employed, either during my employment with Generation Solutions or for a period of one year after my termination of employment with Generation Solutions. I understand that engaging in such activity will result in my being disqualified for rehire with Generation Solutions. Such activity will also result in a monetary penalty assessed the client.

Electronic Signature of Applicant *

Date *

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PERSONAL INFORMATION

DESIRED EMPLOYMENT

SERVICE RECORD

EMPLOYMENT HISTORY

Most Recent Employer

Previous Employer

Click to Add More Previous Employers

Previous Employer

Previous Employer

PERSONAL REFERNCES

References 1

References 2

References 3

LICENSURE

DISCLOSURE STATEMENT

CONDITIONS OF EMPLOYMENT

AVAILABILITY

AUTHORIZATION