Date: 4/24/2014

Application Form

Franchise 857

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 2 - General Information

Number Question Effective Date Expiration Date
1.0 Position Applied For: (required)  
 
 
 
 
 
2.0 Date of Application (required)  
     
3.0 What days/times are you available to work: (required)  
     
3.5 How many hours do you ideally want to work? (required)  
 
 
 
 
4.0 What date are you available for Employment? (required)  
     
5.0 Social Security Number (needed for background check)  
  (Numeric Answer Only)    
6.0 Current Address (required)  
     
6.5 City/State/ZIP (required)  
     
7.5 How long have you resided at your current address? (required)  
     
8.1 Previous Address (required)  
     
8.5 How long at this address? (required)  
     

Section 3 - Employment Information

Number Question Effective Date Expiration Date
5 Are you eligible to work in the United States? (Proof of eligibility will be required before you can be employed.) (required)  
     
6 Have you ever been convicted of/or plead guilty to a crime AT ANY TIME? (required)  
     
7 If yes, please explain: (give date, location, charge, etc.) (Please note that in order to be hired by Comfort Keepers, you must be Bondable.)  
     
8 Do you have a valid drivers license? (required)  
     
9 DL# (needed for background check) (required)  
  (Numeric Answer Only)    
10 State of Issue (required)  
     
11 Have you had any moving violations AT ANY TIME? (required)  
     
12 If yes, please describe:  
     
13 Do you have auto insurance IN YOUR NAME? (required)  
     

Section 4 - Education

Number Question Effective Date Expiration Date
1A Do you have a High School Diploma? (required)  
     
1B Name and City  
     
2A Do you have a College Degree? (required)  
     
2B Name and City  
     
2E Course or Major  
     
3A Other Education (Please Specify)  
     

Section 5 - License/Certifications

Number Question Effective Date Expiration Date
1.0 Are you currently registered in NC as a CNA? (required)  
     
2.0 Other Certifications  
     

Section 6 - Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer (required)  
     
2 Start date (required)  
     
3 End Date (required)  
     
4 Address (required)  
     
5 City/State (required)  
     
6 Phone Number (required)  
  (Numeric Answer Only)    
7 Starting / Ending Salary (required)  
  (Numeric Answer Only)    
9 Job Title (required)  
     
10 Name of Supervisor/Email (required)  
     
11 Reason(s) for Leaving: (required)  
     
12 Summarize the nature of the work performed and job responsibilities (required)  
 
13 May we contact for reference? (required)  
     

Section 7 - Second Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer  
     
2 Start Date  
     
3 End Date (required)  
     
4 Address  
     
5 City/State (required)  
     
6 Phone Number  
  (Numeric Answer Only)    
7 Starting/Ending Salary  
  (Numeric Answer Only)    
9 Job Title  
     
10 Name of Supervisor/Email  
     
11 Reason(s) for Leaving:  
     
12 Summarize the nature of the work performed and job responsibilities  
 
13 May we contact for a reference?  
     

Section 8 - Other Employers and Comments

Number Question Effective Date Expiration Date
1 Please list other employers, dates, and responsibilities  
 
2 Please explain any gaps in employment  
 

Section 9 - Skills and Personal Experience

Number Question Effective Date Expiration Date
1 Number of years experience (paid or personal) providing care? (required)  
  (Numeric Answer Only)    
2 I am able to provide personal care? (required)  
     
3 Experience with bathing/dressing/toileting? (required)  
     
4 Are you able to perform light housekeeping? (required)  
     
5 Experience with clients with alzheimers/dementia? (required)  
     
6 Can lift up to 25lbs? (required)  
     
7 Experience with hospice/dying clients? (required)  
     
8 Are you comfortable driving clients to appts? (required)  
     
9 Experience with a hoyer lift? (required)  
     

Section 10 - Professional References

Number Question Effective Date Expiration Date
1A Reference 1 (required)  
     
1B Telephone Number AND Email (required)  
  (Numeric Answer Only)    
1C Relationship/Years known (required)  
     
2A Reference 2 (required)  
     
2B Telephone Number AND Email (required)  
  (Numeric Answer Only)    
2C Relationship/Years known (required)  
     
3A Reference 3 (required)  
     
3B Telephone Number AND Email (required)  
  (Numeric Answer Only)    
3C Relationship/Years known (required)  
     

Section 11 - 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)  
     

Section 12 - Signature of Applicant

Number Question Effective Date Expiration Date
1 Please Initial and Date (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.