Application Form We are hiring Direct Support Staff, Drivers, Companions, CNA's, LPN's and RN's!Apply Today! Step 1 of 17 5% Position your are applying for Direct Support Staff LPN CNA RN Companion Driver Personal Information First Middle Last Date of Birth Date Format: MM slash DD slash YYYY Social Security NumberDriver's License Number Current Address Street Address City State / Province / Region ZIP / Postal Code Previous Address Street Address City State / Province / Region ZIP / Postal Code If lived less than five (5) years at current address Are you atleast 18 years of age?YesNoAre you legally eligible for employment in the United States of America?YesNoAre you fluent in any language besides English?YesNoIf yes, please specifyHave you ever worked with residents with mental disabilities / developmental disabilities?YesNoIf yes, please specify: facility, location, supervisor, time spent, and reasons for departure Are you related to any Golden Generation, LLC employees?YesNoIf yes, who?Have you previously been employed by Golden Generation, LLC?YesNoIf yes, please specifyMay we contact your current or two most recent employers?YesNoIf no, please specifyName of Employer First Last Phone NumberName of Employer First Last Phone Number Have you ever been convicted of a crime?YesNoHave you ever been charged with an individual's injury due to gross negligence?YesNoHave you ever been convicted of sexual misconduct or harassment?YesNoHave you ever been charged or convicted for verbally, physically, or mentally abusing an individual?YesNoIf yes, please specify. Please note a conviction will hinder employment. Golden Generations, LLC puts all individuals' safety first.Are you willing to submit to random drug testing during employment?YesNo Do you have a High School Diploma or GED?High School DiplomaGEDNoDo you own a valid CPR Card?YesNoDo you own a valid First Aid Card?YesNoDo you own a valid CPI Card?YesNoDo you own a valid Driver's License?YesNoIn which state is your valid Driver's License issued?If no, please specifyHas your Driver's License ever been suspended or revoked?YesNoIf yes, please specify state and reason In case of emergency, list next of kin or preferred contact First Last PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Relationship Applicant's SignatureApplication Date Date Format: MM slash DD slash YYYY Before being considered for employment, the following steps must be completed. A Cogent Gap Background Check followed by a Clearence Letter from DBHDD and / or DCH. A completed Job Application along with a signed Job Description. A current resume. A medical physical, T.B. Test and Communicable Disease Statement signed by your physician. A copy of your Driver's License, Social Security Card, CPR Card and First Aid Card. A seven (7) year driver's record, signed by the Motor Vehicle Department.I have been aware that the above checklist must be adhered to before being considered for employment.*YesI fully understand that failure to adhere to above checklist can hinder the hiring process.*YesI am aware that submitting faulty documentation will result in being REMOVED from employment consideration.*Yes High School AttendedHigh School Address Street Address City State / Province / Region Did you graduate?YesNoCollege or University AttendedCollege or University Address Street Address City State / Province / Region Did you graduate?YesNoTechnical, Trade, or Businiess School AttendedTechnical, Trade, or Businiess School Address Street Address City State / Province / Region Did you graduate?YesNoLicenses and CertifcatesList Issuing State, Professional, Trade, etc. Certificate Number and Expiration Date. Begin with your most recent experiences, account for the last 10 years.Employer #1PhoneAddress Street Address City State / Province / Region ZIP / Postal Code PositionReason(s) for departure Begin with your most recent experiences, account for the last 10 years.Employer #2PhoneAddress Street Address City State / Province / Region ZIP / Postal Code PositionReason(s) for departure Begin with your most recent experiences, account for the last 10 years.Employer #3PhoneAddress Street Address City State / Province / Region ZIP / Postal Code PositionReason(s) for departure Personal Reference #1 First Last PhoneRelationship and years known Personal Reference #2 First Last PhoneRelationship and years known Business Reference #1 First Last PhoneRelationship and years known Business Reference #2 First Last PhoneRelationship and years known I hereby certify that all the statements made in this application are true, complete, and correct to the best of my knowledge and belief. I realize and understand that any inclusion of false information or omission of material could result in DISMISSAL from employment or REMOVAL of my application from further consideration. I also hereby certify that I am not suffering from a communicable disease or mental health disorder which would hinder my job performance, nor have I been charged with or convicted of a crime involving abuse, neglect, exploitation, or depravation of a child or adult. I hereby authorize all my employers and Police / Sheriff Department (unless otherwise stated) to release any and all information in regards to my employment as requested.*Yes
