Date: 5/23/2013

Application Form

Franchise 507

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 1 - Date Of Application
Number Question Effective Date Expiration Date
1 Date of Application (required)  
     

Section 3 - Position
Number Question Effective Date Expiration Date
1 What position are you applying for? (required)  
 
 
 
2 Tell me about your caregiving or CNA work experience. (required)  
 
3 We cannot guarntee hours due to the nature of the work. Is that okay? (required)  
     
4 What days of the week are you available to work? (required)  
     
5 We require our staff to work every other weekend. Are you available to work every other weekend? (required)  
     
6 Which shift best meets what you are available to work? (required)  
 
 
 
 
 
7 Do you have experience with Alzheimers Disease? (required)  
     
8 Do you have experience with dementia? (required)  
     
9 Are you a current licensed CNA? (required)  
     
10 If you answered yes, where were you trained? (required)  
     
11 Do you have experience with a gait belt or hoyer lift? (required)  
     
12 If yes, please explain. (required)  
     

Section 4 - Referral Source
Number Question Effective Date Expiration Date
1 How were you referred to Comfort Keepers? (required)  
 
 
 
 
 
2 If an employee or relative, what is the name of said employee? (required)  
     
3 If internet or advertisement, what is the source? (required)  
     

Section 5 - Personal Information & Data
Number Question Effective Date Expiration Date
1 What date are you available for employment? (required)  
     
2 Type of Employment desired? (required)  
 
 
3 Are you able to meet the attendance requirements of this position? (required)  
     
4 Have you previously applied for a position at Comfort Keepers? (required)  
     
5 If YES, When and Where? (required)  
     
6 Have you previously worked for Comfort Keepers? (required)  
     
7 If YES, When & Where? (required)  
     
8 Are you eligible to work in the United States? (Proof of Eligibility will be required prior to employment) (required)  
     
9 Are you presently on LAYOFF and/or subject to recall from another company? (required)  
     
10 If YES, please explain: (required)  
     
11 Have you ever been convicted of/or plead guilty to a crime (other than minor traffic violations)? (required)  
     
12 If YES, please explain: (give date, location, charge, etc...) (required)  
     
13 You must have a dependable automobile, car insurance, and a valid driver's license. Do you have your OWN safe vehicle? (required)  
     
14 Do you have a valid driver's license? (required)  
     
15 Driver's License Number: (required)  
     
16 Driver's License issuing State: (required)  
     
17 Type of Class of Driver's License: (required)  
     
18 Do you have any relatives currently employed by Comfort Keepers? (required)  
     
18 Have you had any moving violations in the past 3 years? (required)  
     
19 Do you have proof of valid auto insurance in your name? (required)  
     
20 If you are under the Age of 18, Can you furnish a work permit?  
     
21 What is your Social Security Number  
  (Numeric Answer Only)    
22 How long have you lived at your current address? (required)  
     
23 Are you at least 23 years old? (required)  
     
24 Are you able to lift, push, and pull up to 25 pounds? (required)  
     
25 Have you or your family received Temporary Assistance for Needy Families(TANF), Food Stamps, or TennCare in the past 18 months? (required)  
     

Section 6 - Educational Background
Number Question Effective Date Expiration Date
1 What is your highest level of education completed? (required)  
 
 
 
 
2 Are you still attending a school or college? (required)  
     
3 If yes, when is your anticipated graduation? (required)  
     

Section 7 - Most Recent Employment History
Number Question Effective Date Expiration Date
1 What is the name of the employer? (required)  
     
2 Telephone Number: (required)  
  (Numeric Answer Only)    
3 Address: (required)  
     
4 City: (required)  
     
5 State (required)  
     
6 Job Title: (required)  
     
7 Immediate Supervisor: (required)  
     
8 Reason for leaving (required)  
 
 
 
9 If you QUIT, did you give a notice? (required)  
     
10 How much of a notice did you give? (required)  
     
11 If you were Terminated, please explain briefly: (required)  
     
12 Please mark dates Employed: (required)  
 
13 Are you still employed at this employer? (required)  
     
14 What was your starting rate of Pay? (required)  
  (Numeric Answer Only)    
15 What type of pay? (required)  
 
 
16 What was your final rate of pay? (required)  
  (Numeric Answer Only)    
17 May we contact this employer for a reference? (required)  
     

Section 8 - 2nd. Most Recent Employment History
Number Question Effective Date Expiration Date
1 What is the name of the Employer? (required)  
     
2 Telephone Number: (required)  
  (Numeric Answer Only)    
3 Address: (required)  
     
4 City: (required)  
     
5 State: (required)  
     
6 Job Title: (required)  
     
7 Immediate Supervisor: (required)  
     
8 Reason for leaving: (required)  
 
 
 
9 If you QUIT, did you give a notice? (required)  
     
10 How much notice did you give? (required)  
     
11 If you were Terminated, please explain briefly: (required)  
     
12 Please mark dates Employed: (required)  
 
13 Are you still employed at this employer? (required)  
     
14 What was your starting rate of pay? (required)  
  (Numeric Answer Only)    
15 What type of pay? (required)  
 
 
16 What was your final rate of pay? (required)  
  (Numeric Answer Only)    
17 May we contact this employer for a reference? (required)  
     

Section 9 - 3rd. Most Recent Employment Hisstory
Number Question Effective Date Expiration Date
1 What is the name of the Employer? (required)  
     
2 Telephone Number: (required)  
  (Numeric Answer Only)    
3 Address: (required)  
     
4 City: (required)  
     
5 State: (required)  
     
6 Job Title: (required)  
     
7 Immediate Supervisor: (required)  
     
8 Reason for leaving: (required)  
     
9 If you Quit, did you give a notice? (required)  
     
10 How much notice did you give? (required)  
     
11 If you were Terminated, please explain briefly: (required)  
     
12 Please mark dates of Employment: (required)  
 
13 Are you still employed at this employer? (required)  
     
14 What was your starting rate of pay? (required)  
  (Numeric Answer Only)    
15 What type of Pay? (required)  
 
 
16 What was your final rate of pay? (required)  
  (Numeric Answer Only)    
17 May we contact this employer for a reference? (required)  
     

Section 10 - Please list 3 references that are NOT relatives
Number Question Effective Date Expiration Date
1 Reference Name #1: (required)  
     
2 Reference #1 Telephone Number: (required)  
  (Numeric Answer Only)    
3 Number of years knowing reference #1 (required)  
  (Numeric Answer Only)    
4 What is your relationship to reference #1 (required)  
     
5 Reference Name #2: (required)  
     
6 Reference #2 Telephone Number: (required)  
  (Numeric Answer Only)    
7 Number of years knowing reference #2 (required)  
  (Numeric Answer Only)    
8 What is your relationship to reference #2 (required)  
     
9 Reference Name #3: (required)  
     
10 Reference #3 Telephone Number: (required)  
  (Numeric Answer Only)    
11 Number of years knowing reference #3 (required)  
  (Numeric Answer Only)    
12 What is your relationship to reference #3 (required)  
     

Section 11 - Electronic Signature
Number Question Effective Date Expiration Date
1 By signing your name below you are stating that the facts you have submitted on this application are true and complete. Any falsification or misrepresentation of information will be cause for rejection of my 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.

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 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 and signed by the owner(s).

If I am employed, I agree to comply with and be bound by the safety and health rules and regulation, and rules of conduct of Comfort Keepers.

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 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.

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.

If required, I agree to a drug testing prior and during employment or for post accident occurences.