Genesic Health CNA Application Form

Employment Application

Thank you for your interest in joining Genèsic Health. It is policy of the company to provide equal employment to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.
Applicant Information
Name

First NameLast Name
E-mail
Main Phone Number

Area CodePhone Number
Additional Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Educational Background
GED or High School Diploma
Name of School Attended
Year of Graduation
Name of College/Vocational School
Year of Graduation
Additional Name of College/Vocational School
Year of Graduation
List certifications of training
Military Training
Military Training
Branch of Service
Specialized Training
Years of Service
Emergency Contacts
Main Emergency Contact

First NameLast Name
Main Phone Number

Area CodePhone Number
Relationship to You
Example: Spouse, Sibling, Child
Address of Main Emergency Contact

Street Address

Street Address Line 2

CityState

Zip Code
Alternate Emergency Contact

First NameLast Name
Relationship to You
Example: Spouse, Sibling, Child
Alternate Contact Phone Number

Area CodePhone Number
Address of Alternate Contact

Street Address

Street Address Line 2

CityState

Zip Code
Work and Position Info
Number of Years of CNA Experience
Current Hourly Rate or Hourly Rate from Previous Job
Please Upload Most Current Pay Stub

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Desired Salary
Are You Interested in Full Time or Part Time Work
Please upload your resume or summary experience. Document may also be emailed to GenesicHealth@gmail.com

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Reference 1

First NameLast Name
Reference 1 Contact Info

Area CodePhone Number
Reference 1 E-mail
example@example.com
Reference 2

First NameLast Name
Reference 2 Contact Info

Area CodePhone Number
Reference 2 E-mail
example@example.com
Reference 3

First NameLast Name
Reference 3 Contact Info

Area CodePhone Number
Reference 3 E-mail
example@example.com
Availability
What date can you start?

MonthDayYear
Monday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Tuesday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Wednesday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Thursday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Friday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Saturday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Sunday

:HourMinutesAM/PM Option
Until
until :HourMinutesAM/PM Option
Background Check/Drug/Health Screening

As an employee, a background check is required for employment. This must be done within 5-10 days or as soon as possible to keep the application active. (Lee County Jail 229-759-3334)
All employees will be required to do a drug screening. Have you recently had a drug screening?
Please upload a copy of your results. Document may also be emailed to GenesicHealth@gmail.com

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Have you tested positive for COVID in the last 10 days
Have you been around someone who has tested positive for COVID in the last 10 days
Have you had any of the following symptoms in the last 10 days?
I certify the information provided is accurate and correct.
Should be Empty:

Employment Application

Background Check/Drug/Health Screening