Date: 7/29/2015

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 Number
Mobile Phone
Email *

Section 1 - General

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

Section 2 - Education and Training

Number Question Effective Date Expiration Date
1 Do you have a high school diploma or GED? (required)  
     
2 Please list any types of diplomas, degrees held, or certifications received (eg: CPR). (If this question does not apply to you, please type N/A) (required)  
     
3 What licenses do you hold? (required)  
 
 
 
 
 
4 What is the license-issuing authority or board which issued your license? (If this question does not apply to you, please type N/A) (required)  
     
5 Enter your license # (If this question does not apply to you, please type N/A) (required)  
     
6 License expiration date (if applicable)  
     

Section 3 - Security

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

Section 4 - Availability

Number Question Effective Date Expiration Date
1 Please provide specific times and days 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 available to do overnights? (required)  
     

Section 5 - Background and Experience

Number Question Effective Date Expiration Date
1 Please provide the names, addresses, and telephone numbers of all institutions, private patients, and agencies worked for within the past year. Please provide the reason for leaving, employer name, and supervisor name. (Please provide as much detail as possible regarding departments or areas of work and dates or length of time at each job) (required)  
 
2 I hereby authorize Comfort Keepers to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination (required)  
     

Section 6 - Insurance

Number Question Effective Date Expiration Date
1 Please provide your malpractice insurance carrier (name and address) (If you do not have malpractice insurance, please put N/A) (required)  
     
2 What is your malpractice insurance policy number? (If you do not have malpractice insurance, please put N/A) (required)  
     



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.