Name: Generational Home Care
Address: 7114 W. Capitol Drive Lower Level, Milwaukee, WI, 53216
Price range: $$

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time. Please read "Applicant Note” below. Complete all pages of this application. Print clearly. Incomplete or illegible applications may not be accepted. If more space is needed to complete any question, use comments section on the back. Application will be valid for 90 days.
Personal Information
Today's Date*
MM slash DD slash YYYY
Email*
Position Applied For*
Name*
First Last
Current Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Alternate Phone
Have you ever submitted an application here before?*
- Yes
- No
When?
Have you ever been employed here before?*
- Yes
- No
When?

Work History
Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential. Please list two of your most current employers.
First Previous Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Contact Name*
First Last
Contact Number*
Can we contact employer?*
- Yes
- No
Responsibilities*
Reason for Leaving*
Rate of Pay: (weekly/biweekly/salary)*
Start Date*
Month
Day
Year
End Date*
Month
Day
Year
Second Previous Employer
Address
Street Address Address Line 2 City State ZIP Code
Contact Name
First Last
Contact Number
Can we contact employer?
- Yes
- No
Responsibilities
Reason for Leaving
Rate of Pay: (weekly/biweekly/salary)
Start Date
Month
Day
Year
End Date
Month
Day
Year

References (Do not include relatives)
Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references.
Name*
First Last
Home Phone*
Work Phone*
Best Time of Day to Call*
Relationship*
Number of Years Known*
Name*
First Last
Home Phone*
Work Phone*
Best Time of Day to Call*
Relationship*
Number of Years Known*
I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Generational Home Care, LLC and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
Signature*
Reference Checking Consent and Authorization
Please read the information on this form carefully and completely. I have applied for employment Generational Home Care, LLC and have provided information about my previous employment. I authorize Generational Home Care, LLC to conduct a reference check with my present and/or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary and employment history. My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Generational Home Care, LLC, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Generational Home Care, LLC from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Generational Home Care, LLC. I further authorize Generational Home Care, LLC to obtain feedback and references from my supervisors over the course of my previous employment. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
Name*
First Last
Last 4 digits of Social Security Number*
Signature*
Date*
Month
Day
Year
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Generational Home Care