Date: 4/16/2014

Application Form

Franchise 725

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
1.0 Position(s) Applying For:  
     
2.0 Date of Application  
     
3.0 Referral Source:  
 
 
 
 
 
4.0 Name: (Last, First, Middle) (required)  
     
5.0 Social Security Number  
  (Numeric Answer Only)    
6.0 Email Address  
     
7.1 Current Street Address  
     
7.2 City  
     
7.3 State  
     
7.4 Zip Code  
     
7.5 How long at this address?  
     
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:  
     
10.0 Cell Phone:  
     
11.0 Best time to call you:  
     

Section 2 - Employment Information

Number Question Effective Date Expiration Date
1 What date are you available for Employment?  
     
2 Type of employment desired (Type All that Apply) Full Time, Part Time, Temporary, Seasonal.  
     
3 Are you able to work overtime, if required?  
     
4 Are you able to meet the attendance requirements of the position?  
     
5 Have you previously applied for a position at Comfort Keepers?  
     
6 If Yes, then when?  
     
7 Have you previously worked at Comfort Keepers?  
     
8 If Yes, then when?  
     
9 Are you eligible to work in the United States? (Proof of eligibility will be required before you can be employed.)  
     
11 If you are under 18, can you furnish a work permit?  
     
12 Have you ever been convicted of/or plead guilty to a crime (other than minor traffic violations)?  
     
13 If yes, please explain: (give date, location, charge, etc.) (Please note that in order to be hired by Comfort Keepers, you must be Bondable.)  
     
14 If the job requires, do you have a valid drivers license?  
     
15 DL#  
  (Numeric Answer Only)    
16 Type:  
     
17 State of Issue  
     
18 Have you had any moving violations in the past 3 Years?  
     
19 If yes, please describe:  
     
20 Do you have any relatives currently employed by Comfort Keepers?  
     
21 If yes, please list:  
     
22 Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?  
     
23 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.)  
     
24A Name of person to be contacted in case of an emergency (Last, First, Middle)  
     
24B Relationship  
     
24C Telephone Number  
     
24D Address  
     
24E City, State, Zip  
     

Section 3 - Education

Number Question Effective Date Expiration Date
1A Do you have a High School Diploma?  
     
1B Name and City  
     
1C How many years attended?  
  (Numeric Answer Only)    
1D Graduate?  
     
1E Course or Major  
     
2A Do you have a College Degree?  
     
2B Name and City  
     
2C How many years attended?  
  (Numeric Answer Only)    
2D Graduate?  
     
2E Course or Major  
     
3A Do you have a Graduate Degree?  
     
3B Name and City  
     
3C How many years attended?  
  (Numeric Answer Only)    
3D Graduate?  
     
3E Course or Major  
     
4A Did you Attend Business or Trade School?  
     
4B Name and City  
     
4C How many years attended?  
  (Numeric Answer Only)    
4D Graduate?  
     
4E Course or Major  
     
5A Other Education (Please Specify)  
     

Section 4 - Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer  
     
2 Start Date  
     
3 End Date  
     
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 5 - Second Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer  
     
2 Start Date  
     
3 End Date  
     
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 - Third Most Recent Employer

Number Question Effective Date Expiration Date
1 Employer  
     
2 Start Date  
     
3 End Date  
     
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 7 - Other Employers and Comments and Availability

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

Section 8 - Professional References

Number Question Effective Date Expiration Date
1A Reference 1  
     
1B Telephone Number  
  (Numeric Answer Only)    
1C Years Known  
  (Numeric Answer Only)    
1D Relationship  
     
2A Reference 2  
     
2B Telephone Number  
  (Numeric Answer Only)    
2C Years Known  
  (Numeric Answer Only)    
2D Relationship  
     
3A Reference 3  
     
3B Telephone Number  
  (Numeric Answer Only)    
3C Years Known  
  (Numeric Answer Only)    
3D Relationship  
     

Section 9 - 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)  
     



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.