Application Form

Office Location

Select Office Location

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - Personal

Date of Application

Full Name (required)

Address - Street, City, Zip Code (required)

Primary Phone number (required)

Social Security Number

Position Applying For (required)

Section 2 - APPLICANT REFERRAL SOURCE

How did you hear about Comfort Keepers (required)

Name of Referrer

Section 3 - Employment Information

What date are you available for Employment (required)

What days of the week are you available for work? (required)

What hours of the day are you available for work? (required)

Have you previously applied for a position at Comfort Keepers?

Yes No

Have you previously worked at Comfort Keepers? (required)

Yes No

If so, When?

Are you legally eligible to work in the United States? (Proof of eligibility is required) (required)

Yes No

Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, and may include a credit check, motor vehicle check and drug screen. (Please note that some positions require you to be insured and bonded.) Please check if in agreement: (required)

Yes No

Do you have any relatives currently employed by Comfort Keepers?

Yes No

If yes, please list:

Section 4 - General Information

Do you have reliable transportation to and from work? (required)

Yes No

Do you have valid Driver's License? (required)

Yes No

Do you have working cell phone? (required)

Yes No

Do you have valid email?

Yes No

Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?

Yes No

If no, describe the functions that cannot be performed:

Have you ever been convicted of/or plead guilty to a crime (other than minor traffic violation)

Yes No

If so, please explain. Please note that in order to be hired by Comfort Keepers you must be bondable.

Show Plain Text

Section 5 - Educational Background

Do you have a high school diploma or Equivalent (GED) (required)

Yes No

Name of School/ City where located

How Many Years Attended

Graduated

Yes No

Type of School ( Trade School, Technical School/College, etc.)

Name of School/ City where located

How Many Years Attended

Graduated

Yes No

Course or Major

Type of School (Trade School,Technical College, College, other)

How many years attended

Name of School/ City where located

Graduated?

Yes No

Course or Major

Did you have certificate for RN,CNA, MA, or LPN in the past

Yes No

Do you have a current certificate as RN, CNA, MA or LPN?

Yes No

Section 6 - Experience

Do you have caregiving experience?

Yes No

If so, please describe.

Show Plain Text

Have you previously done in-home care?

Yes No

Do you have experience in caring for clients with dementia (required)

Yes No

Section 7 - 1st Most Recent Employer

Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Summarize the nature of the work performed and job responsibilities:

Show Plain Text

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

Show Plain Text

May we contact?

Yes No

Hourly Rate Starting:

Hourly Rate Ending:

Section 8 - 2nd Most Recent Employer

Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Summarize the nature of the work performed and job responsibilities:

Show Plain Text

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

Show Plain Text

May we contact?

Yes No

Hourly Rate Starting:

Hourly Rate Ending:

Section 9 - 3rd Most Recent Employer

Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Summarize the nature of the work performed and job responsibilities:

Show Plain Text

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

Show Plain Text

May we contact?

Yes No

Hourly Rate Starting:

Hourly Rate Ending:

Section 10 - Reference 1

Name:

Telephone:

Years Known:

Relationship:

Section 11 - Reference 2

Name:

Telephone:

Years Known:

Relationship:

Section 12 - Reference 3

Name:

Telephone:

Years Known:

Relationship:

Section 13 - Applicants Certification and Agreement

I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date.

Yes No

The employer, Comfort Keepers, is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law. (required)

Yes No

I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Comfort Keepers other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s). (required)

Yes No

If I am employed, I agree to comply with and be bound by the safety and health rules and regulations of conduct of Comfort Keepers.

Yes No

I give the employer and/or its agents, including consumer reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless this employer, its representatives, all persons and organizations/companies for furnishing such information. (required)

Yes No

If required, I agree to drug testing prior and during employment or for post accident occurrences. (required)

Yes No

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

Franchise 586 Application Form

Office Location

Personal Information

Section 1 - Personal

Section 2 - APPLICANT REFERRAL SOURCE

Section 3 - Employment Information

Section 4 - General Information

Section 5 - Educational Background

Section 6 - Experience

Section 7 - 1st Most Recent Employer

Section 8 - 2nd Most Recent Employer

Section 9 - 3rd Most Recent Employer

Section 10 - Reference 1

Section 11 - Reference 2

Section 12 - Reference 3

Section 13 - Applicants Certification and Agreement