Date: 7/31/2014

Application Form

Franchise 613

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General

Number Question Effective Date Expiration Date
1 How did you hear about Comfort Keepers? (required)  
 
 
 
 
 
2 If other, please tell us where you heard about us.  
     
3 If employee referral, please tell us who referred you.  
     
4 Do you have a high school diploma or GED? (required)  
     
5 Do you have the physical ability to lift, push and pull up to 25 pounds? (required)  
     
6 Which position are you applying for? (required)  
 
 
 
 
 
7 Starting pay for $10.00 per hour for companions, $11.00 for CHHA and $116 per day for Live-In. Is this pay acceptable? (required)  
     
8 Do you have reliable transportation to transport our clients? (required)  
     
9 If yes, please state year, make and model of vehicle.  
     
10 Do you have a valid driver's license? (required)  
     
11 Are you fluent in any other languages? If so, please list.  
     

Section 2 - Security

Number Question Effective Date Expiration Date
1 We do extensive background checks. Do you have a criminal record? (required)  
     
2 Do you have more than 3 points on your driving record? (required)  
     
3 Can you pay $40.00 for a background check? (This is required BEFORE hiring and is refundable after 90 days of successful employment.) (required)  
     
4 Do you have a Facebook or Twitter account? If so, may we check? Please provide information. (required)  
     

Section 3 - Availability

Number Question Effective Date Expiration Date
1 Please provide specific times and dates that you are available to work? Please list days, start times and end times (ie., Monday thru Sunday, 12:00 am - 12:00 am) (required)  
 
2 Are you currently employed? If so, where? If not, who was your last employer? (required)  
 
3 Are you available to do overnights? (required)  
     
4 Are you available for occasional weekend on-call?  
     
5 What would your last employer say about you?  
 



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.