Careers | Generations Home Care

Name*
First Last
*
City State / Province / Region
Contact Info*
Primary Phone Number
Email Address*
Email Address
Resume and Experience
Drop files here or

Max. file size: 256 MB.

If you are a CNA, LNA or HHA, your license must be in good standing. Do you have a valid professional license?
- Yes
- No
License Type*
License Number/ID*
Issuing College, Technical School, or Organization*
Issue Date*
Month
Day
Year
Expiration Date*
Month
Day
Year
State
Do you have another professional license or certification?*
- Yes
- No
If yes, what license or certification?
If yes, what license or certification?
Has your license, registration, or certification ever been investigated, revoked, suspended, limited, or subject to discipline, by any board or governing authority?*
- Yes
- No
If yes, please explain:

Education*
please select the highest education level you have completed:
- Primary School
- High School
- College
Name of School*
Address*
City State / Province / Region
What was your GPA/Scale (i.e. 3.5/4.0)*
Do you have a degree?*
- Yes
- No
If so, what Degree? (AS, BS, etc.)
Field of Study

Reference Information
Have any of your relatives ever worked for this company?*
- Yes
- No
If yes, please provide the name:
Do any of your friends work here?*
- Yes
- No
If yes, please provide the name:
Please list three references of a professional nature
Name:
Relationship:
Company:
Phone Number:
Name:
Relationship:
Company:
Phone Number:
Name:
Relationship:
Company:
Phone Number:

Criminal Convection History*
I agree that I have not been convicted of a crime such as molestation, rape, battery, neglect, exploitation, felony theft, or any other substantially related crime to a dependent population.
- I Agree
- I Don't Agree
- "Molest" means to annoy or to meddle with so as to trouble or harm; to make improper sexual advances.
- "Rape" means to have sexual intercourse with a person forcibly and with consent; any sexual, violent or outrageous assault.
- "Battery" means knowingly or intentionally touching another person in a rude or angry manner(i.e.m grabbing or shoving in a rude, angry manner; slapping or hitting; and knocking someone to the floor).
- "Neglect" means placing a dependent in a situation that may endanger his/her life or health (i.e., abandoning or cruelly confining a dependent or depriving a dependent of necessary support, including food, clothing, shelter or medical care.
- "Dependent" means a person of any age who is mentally or physically disabled who is under the care of another person.
- "Exploitation" means unauthorized use of an adult dependent or his/her resources for one's own profit or advantage, or for the profit or advantage of another.
- "Theft" means a criminal act in which property belonging to another is taken without that persons consent.

Application Agreement
I fully understand that I must report all accidents to my immediate supervisor and to Southland Home Health and Hospice. I also understand that I must wear all required personal protective equipment (PPE). The penalty for not wearing PPE is disciplinary action, up to and including termination. In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment. I give Southland Home Health and Hospice permission to use any information in this application to enable it and its agents to verify the information contained in this application 1 also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Southland Home Health and Hospice with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Southland Home Health and Hospice may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Southland Home Health and Hospice, its agents, and affiliated entities, as well any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure or such information. In consideration of my employment and of my being considered for employment by Southland Home Health and Hospice, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Southland Home Health and Hospice or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative or Southland Home Health and Hospice, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results. I understand that Southland Home Health and Hospice is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional's practice, The Professional fully indemnifies Southland Home Health and Hospice against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.
- I have read, understood and agree to the above statement and to the terms and conditions for the use of electronic signature.

Careers Form

Step 1 of 11

Schedule

What Professional License Certifications Do you Have?

Employment Status

Reference Information

Please list three references of a professional nature

EEO Information

Please identify your ethnicity.

Application Agreement