Rogers Intergenerational Services
Several companies bringing a warm environment designed to service the needs of all generations in the areas of childcare, assisted living, and home health care.
966 East 146th Street
Cleveland, Ohio 44110
Phone: (216) 851-1853
Fax: (216) 851-1865

Employment Application

Personal Information

Positions applied for:
Email Address:
Street Address:
Zip Code:
Phone Number:
Are you at least 18 years of age

Employment History

May we contact your present/past employers?
If no, please explain why:
If not applicable, list US military, volunteer work, or personal references:
Company: Location:
Phone: Job Title:
Supervisor: Dates Worked (From/To):
Salary: Reason for Leaving:


Please provide the names of at least three persons not related to you, whom you have known for at least one year.



Total Hours Available Per Week:
Hours of Availability (From/To):
Are you legally able to be employed in the US? (Proof of citizenship or immigration status is required upon employment)
How did you hear of the job?
Which location are you applying for?
How far do you live from location?
Do you have the transportation to work?
On what day will you be available to work?
Desired salary:
Please submit a resume:

Additional Information

Do you have a friend or relative in our employ?
If yes, state name and position:
Have you been previously employed by our company?
If yes, where, when, and in what capacity?
In the past 7 years, have you ever been convicted of a crime, excluding misdemeanors and traffic violations?
If yes, please describe in full: (A conviction will not necessarily bar you from employment)


I certify that the information I have given on this application is true and complete and understand that any false or misleading information given, or the omission of any pertinent information may result in my discharge at any time, if I am hired. I hereby authorize the Company to investigate my record with my former employers and personal references. If hired, I agree to abide by the policies, rules, and expectations of the Company. I also understand that my employment is "at will" and that I can resign at any time and that I can be terminated at any time. Nothing herein or during my employment shall be considered an employment contract.

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