Date: 9/2/2014

Application Form

Franchise 648

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.

Office Location

Select Office Location:

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 Information

Number Question Effective Date Expiration Date
1 How did you hear about Comfort Keepers? (required)  
     
1A Why would you be our best choice for a Comfort Keeper? (required)  
     
1B Which Position are you applying for? CNA or Caregiver (required)  
     
1C How many years of experience do you have? (required)  
  (Numeric Answer Only)    
1D Are you currently employed? (required)  
     
2A Have you previously worked at Comfort Keepers? (required)  
     
2B If so, When?  
     
3A Are you legally eligible to work in the United States? (Proof of eligibility is required)  
     
4A 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:  
     
5A You will need to have reliable transportation to and from work and for travel between worksites, if required? (required)  
     
5B Do you have a safe automobile, carry auto insurance, & a valid license? (required)  
     
5C Do you understand this position may require you to drive 20-35 minutes from your home? (required)  
     
6A Do you have any relatives currently employed by Comfort Keepers?  
     
6B If yes, please list:  
     
7A Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?  
     
7B Do you have the physical ability to lift, push, and pull up to 25 pounds?  
     
7C If no, describe the functions that cannot be performed:  
     
8A We cannot guarantee hours due to the nature of the work. Is that acceptable?  
     
8B What is the ideal number of hours you would like to work each week? (required)  
  (Numeric Answer Only)    
8C Tell us the earliest time you would be willing or able to start each morning. (required)  
  (Numeric Answer Only)    
8D How late in the evening are you able to work? (required)  
  (Numeric Answer Only)    
8E All employees are required to work some form of a weekend (example: every Saturday and no Sundays,every Sunday no Saturdays)Can you commit to working weekends to meet this requirement? (required)  
     

Section 2 - Educational Background

Number Question Effective Date Expiration Date
1 Type of School (High School/GED/College)  
     
2 Name/City  
     
3 How Many Years Attended  
 
 
 
 
4 Graduated  
     
5 Course or Major  
     
6 Type of School (High School/GED/College)  
     
7 Name/City  
     
8 How Many Years Attended  
 
 
 
 
9 Graduated  
     
10 Course or Major  
     

Section 3 - 1st Most Recent Employer

Number Question Effective Date Expiration Date
1. Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Summarize the nature of the work performed and job responsibilities:  
 
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
 
14. May we contact?  
     
15. Hourly Rate Starting:  
     
16. Hourly Rate Ending:  
     

Section 4 - 2nd Most Recent Employer

Number Question Effective Date Expiration Date
1. Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Summarize the nature of the work performed and job responsibilities:  
 
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
 
14. May we contact?  
     
15. Hourly Rate Starting:  
     
16. Hourly Rate Ending:  
     

Section 5 - 3rd Most Recent Employer

Number Question Effective Date Expiration Date
1. Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Summarize the nature of the work performed and job responsibilities:  
 
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
 
14. May we contact?  
     
15. Hourly Rate Starting:  
     
16. Hourly Rate Ending:  
     

Section 6 - Reference 1

Number Question Effective Date Expiration Date
1. Name:  
     
2. Telephone:  
     
3. Years Known:  
     
4. Relationship:  
     

Section 7 - Reference 2

Number Question Effective Date Expiration Date
1 Name:  
     

Section 8 - Reference 2

Number Question Effective Date Expiration Date
2. Telephone:  
     
3. Years Known:  
     
4. Relationship:  
     

Section 9 - Reference 3

Number Question Effective Date Expiration Date
1. Name:  
     
2. Telephone:  
     
3. Years Known:  
     
4. Relationship:  
     

Section 10 - References 4

Number Question Effective Date Expiration Date
1 Please explain any gaps in employment. (required)  
 

Section 11 - Personal Care Skills

Number Question Effective Date Expiration Date
1 Tranfer Skills: Select each Transfer Skill that you have experience with and indicate how competent you are: Wheelchair use, Commode use, Gaitbelt, Walker, Stand/Pivot (required)  
 
2 Indicate your comfot level in the use of these types of equipment: Transfer board, Hoyer lift, sit to stand lift, pivot disc. (required)  
 
3 Indicate which of these skills you feel competent to perform. Shower chair bathing, sponge bath, full bed bath, changing an occupied bed, foot-care. (required)  
 
4 Tell us which personal care services you know how to do. Shaving men/women, peri care, Foley bag, ostemy care. (required)  
 
5 We often assist with diabetic testing. Do you know how to read test results and load new strips into a glucometer? (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.