Date: 9/4/2015

Application Form

Franchise 163

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 *
Home Phone * Zip *
Work Phone Driver's License Number
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1.0 Position(s) Applying For:  
2.0 Date of Application (required)  
3.0 Referral Source: (required)  
3.1 If Website/Internet, what site?  
4.0 Name: (Last, First, Middle) (required)  
6.0 Email Address (required)  
7.1 Current Street Address (required)  
7.2 City (required)  
7.3 State (required)  
7.4 Zip Code (required)  
7.5 How long at this address? (required)  
8.1 Previous Street Address  
8.2 City  
8.3 State  
8.4 Zip Code  
8.5 How long at this address?  
9.0 Phone Number: (required)  
10.0 Cell Phone: (required)  
11.0 Best time to call you: (required)  

Section 2 - Employment Information

Number Question Effective Date Expiration Date
1 What date are you available for Employment?  
2 How many hours would you like each week? (required)  
3 Our service is available 24 hours a day, 7 days per week. What days and hours are you available to work for Comfort Keepers? Be very specific Example:M 12a-12a, T 10a-3p, W 12a-12a, etc. (required)  
4 Are you able to work overtime, if required?  
5 Due to the nature of our business, employees are considered part-time. Although, we try to keep you at your desired amount of hours, they may fluctuate based on clients adding or subtracting hours. Is this ok? (required)  
6 What are your wage requirements? (required)  
8 Are you able to meet the attendance requirements of the position? (required)  
9 Have you previously applied for a position at Comfort Keepers? (required)  
10 If Yes, then when?  
11 Have you previously worked at Comfort Keepers? (required)  
12 If Yes, when and in which office were you employed?  
13 Are you eligible to work in the United States? (Proof of eligibility will be required before you can be employed.) (required)  
14 Are you over the age of 18? (required)  
15 Have you ever been convicted of/or plead guilty to a crime (other than minor traffic violations)? (required)  
16 If yes, please explain: (give date, location, charge, etc.) (Please note that in order to be hired by Comfort Keepers, you must be Bondable.)  
17 You must drive yourself to the client's home and have a car with you at all times. Do you have a valid drivers license? (required)  
20 Have you had any moving violations in the past 3 Years? (required)  
21 If yes, please describe:  
22 Do you carry auto insurance at all times? (required)  
25 Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations? (required)  
26 If no, describe the functions that cannot be performed: (Note: we comply with the ADA and consider reasonable accommodations measure that may be necessary to eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.) (required)  
27 As we do work in the homes of our clients. Do you have allergies, such as smoke, pets or other? (required)  
28 Are you willing to work with clients who have pets? (required)  
29 Are you willing to work with clients who smoke? (required)  
30 Do you personally smoke or use tobacco products? (required)  
31 Name of person to be contacted in case of an emergency (Last, First, Middle)  
32 Relationship  
33 Telephone Number  
34 Address  
35 City, State, Zip  

Section 3 - Education and Experience

Number Question Effective Date Expiration Date
8 Are you fluent in a language other than English? Please list.  
1A Do you have a High School Diploma or a GED? (required)  
2A Do you have a College Degree?  
2D Graduate?  
2E Course or Major  
3A Are you a Certified Nurse Assistant? (required)  
3B Is your certification current?  
4A Did you Attend Business or Trade School? (required)  
4D Graduate?  
4E Course or Major  
5A Other Education (Please Specify)  
6a Do you have experience caring for someone in the following situation?  
6b Alzheimer's or Dementia? (required)  
6e Someone who is incontinent or in adult diapers? (required)  
6f If No, are you willing and able to do this? (required)  
6g Someone who has had a stroke? (required)  
6i Someone who has partial or full paralysis? (required)  
6k Someone who has a head injury? (required)  
6m Due to illness or injury: Someone who is combative or verbally abusive? (required)  
6o Someone who is Developmentally, Emotionally or Mentally disabled or handicapped? (required)  
6q Someone who has Parkinson's disease? (required)  
6s Someone who requires diabetic care? (required)  
6t Someone who is bed ridden or has bed sores? (required)  
6u Someone who has had a hip injury or is recovering from hip surgery? (required)  
6w someone who had a spinal cord injury? (required)  
6y Have you ever worked with someone who is in hospice? (required)  
7a Have you ever worked in a nursing home or assisted living? (required)  
7c Have you ever worked with a Hoyer lift or any other lift assist device? (required)  
7d I would describe my cooking skills as: (required)  

Section 4 - Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer (required)  
2 Start Date (mm/dd/yyyy)  
3 End Date (mm/dd/yyyy)  
4 Address  
5 City, State, Zip  
6 Phone Number  
  (Numeric Answer Only)    
7 Starting Salary  
  (Numeric Answer Only)    
8 Ending Salary  
  (Numeric Answer Only)    
9 Job Title  
10 Name of Supervisor  
11 Reason(s) for Leaving: (required)  
12 Summarize the nature of the work performed and job responsibilities  
13 Can we contact your current employer? (required)  

Section 5 - Second Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer  
2 Start Date (mm/dd/yyyy)  
3 End Date (mm/dd/yyyy)  
4 Address  
5 City, State, Zip  
6 Phone Number  
  (Numeric Answer Only)    
7 Starting Salary  
  (Numeric Answer Only)    
8 Ending Salary  
  (Numeric Answer Only)    
9 Job Title  
10 Name of Supervisor  
11 Reason(s) for Leaving:  
12 Summarize the nature of the work performed and job responsibilities  

Section 6 - Other Employers and Comments

Number Question Effective Date Expiration Date
1 Comments and other Skills, licenses/certification and qualifications (including explanation of any gaps in employment)  

Section 7 - Professional References

Number Question Effective Date Expiration Date
1 I understand that professional references are former supervisors, co-workers, teachers, clergy or other people that have known me in a work or education-related capacity and that friends and family are not appropriate professional references. (required)  
1A Reference 1 (required)  
1B Telephone Number (required)  
  (Numeric Answer Only)    
1C Email address  
1D Years Known  
  (Numeric Answer Only)    
1E Relationship (required)  
2A Reference 2 (required)  
2B Telephone Number (required)  
  (Numeric Answer Only)    
2C Email address  
2D Years Known  
  (Numeric Answer Only)    
2E Relationship (required)  
3A Reference 3 (required)  
3B Telephone Number (required)  
  (Numeric Answer Only)    
3C Email address  
3D Years Known  
  (Numeric Answer Only)    
3E Relationship (required)  

Section 8 - Applicants Certification and Agreement

Number Question Effective Date Expiration Date
1 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. (required)  
2 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)  
3 If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Comfort Keepers. (required)  
4 This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personnel file. If I am not hired or have not heard from this employer within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Comfort Keepers. (required)  
5 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)  
6 If required, I agree to a drug testing prior and during employment or for post accident occurrences. (required)  
7 The employer, Comfort Keepers, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicants consideration for employment on a basis prohibited by local, state, or federal law. (required)  
8 Typing my first and last name here certifies that this electronic signature is to be considered the same as if I physically signed a paper job application. (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.