Date: 4/26/2015

Application Form

Franchise 361 and 707
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 Information

Number Question Effective Date Expiration Date
1 Position of Interest? (required)  
     
2 Are you familiar with Comfort Keepers?  
     
2 How did you hear about Comfort Keepers?  
     
3 Have you previously worked at Comfort Keepers?  
 
4 If so, when?  
     
5 Are you legally eligible to work in the United States? (Proof of eligibility is required) (required)  
     
6 Do you have your own vehicle? (required)  
     
7 Do you have a current valid Driver's License? (required)  
     
8 Driver's License number and State issued:  
 
9 Do you have proof of current valid auto insurance?  
     
10 Do you have reliable transportation to and from work and for travel between worksites, if required? (required)  
     
11 Applicants considered for hire are sunject to a thorough background check, including; criminal and may include; credit, motor vehicle and drug screening. (Note: All positions are requried to be insured and bonded) Check if you understand: (required)  
     
12 Have you ever been convicted of or plead guilty to a crime other than a minor traffic violation? (required)  
     
13 If you answered yes to question 12, please describe.  
 
14 Comfort Keepers requires each employee to fulfill some weekends and holiday's. Check if you agree to your requirements for weekends and holiday's. (required)  
     
15 What days and hours are you NOT available for work? (required)  
 
16 Are you able to perform the essential functions of the job for which you applying, with or without reasonable accommodations? (required)  
     
17 If no, describes the functions that cannot be performed:  
 
18 Do you have any relatives currently employed by Comfort Keepers? (required)  
     
19 If yes, please list:  
 

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. Professional Relationship: (required)  
     

Section 7 - Reference 2

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

Section 8 - Reference 3

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



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.