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Are you legally eligible to work in the United States? (Proof of eligibility will be required upon offer of employment)

Yes

No

Are you over the age of 18 years (If no, you may be required to provide authorization)

Yes

No

Can you with or without reasonable accommodation perform the essential functions of this job? (If you have any questions about the functions of the job, please ask the interviewer before answering this question.)

Yes

No

Have you ever applied to Genus Home Care, Inc. before? (If yes, please give date.)

Yes

No

Have you ever worked for Genus Home Care, Inc. before? (If yes, please give date.)

Yes

No

Have you ever been convicted of a felony? (If yes, please explain: )

Yes

No

Do you have a valid driver's license? (For driving positions only.)

Yes

No

Have you been convicted of any moving violations in the past five years? (If yes, please explain: )

Yes

No

Is anyone related to you employed by Genus Home Care, Inc.? (If yes, please give their name and relationship to you. )

Yes

No

What salary or rate of pay do you expect to receive if employed?

Have you ever been fired or asked to resign from a job? (If yes, please expplain. )

Yes

No

On what date would you be available to work?

Days and Hours Available: (If employed, I will notify my supervisor in writing, should my availability change.)

Please list any academic honors, scholarships, offices held, etc. (Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or veteran status.)

Describe any specialized training, apprenticeships, licenses or skills.

Have you received any job-related training in the United States Military?

Yes

No

Please give dates and explanation:

Company Name

Describe your duties

Company Name

Describe your duties

Company Name

Describe your duties

Company Name

Describe your duties

Please provide any other information that you feel will help us in considering your application for employment.

*PLEASE READ CAREFULLY BEFORE SIGNING*
I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Genus Home Care, Inc. (hereinafter referred to as "Genus Home Care, Inc." that such employment with Genus Home Care, inc. is at will, for no specified duration and may be terminated by either Genus Home Care, Inc. or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Genus Home Care, Inc. or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of Genus Home Care, Inc. except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President of Genus Home Care, Inc.

In consideration for employment with Genus Home Care, Inc. if employed, I agree to conform to the rules, regulations, policies and procedures of Genus Home Care, Inc. at all times and understand that such obedience is a condition of employment. I understand that due to the nature of Genus Home Care, Inc. business, attendance and punctuality are considered essential requirements of every job at Genus Home Care, Inc. and that poor attendance or tardiness will result in disciplinary action.

I understand that if offered a position with Genus Home Care, Inc., I may be required to submit to a p re-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result ire withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Genus Home Care, Inc. and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.