Franchise 280 and 1003 Application Form
Application Form
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
*
Last Name
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
State
Alabama
Alaska
American Samoa
Arizona
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District of Columbia
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Louisana
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Maryland
Massachusetts
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Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
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New Hampshire
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New Mexico
New York
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Northern Mariana Islands
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Texas
U.S. Minor Outlying Islands
Utah
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Virginia
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Yukon
Zip
*
Driver's License Number
--
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
AA
AE
AP
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MS
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NE
NV
NH
NJ
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NY
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OR
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UM
UT
VT
VI
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Section 1 -
General Information
What position are you applying for?
(required)
-- Select an Option --
CNA
HHA
Companion
LPN
RN
Have you previously worked at Comfort Keepers?
(required)
Yes
No
Do you have a valid driver license? (driving is required for all positions)
(required)
Yes
No
Do you have reliable transportation to and from work and for travel between worksites, if required?
(required)
Yes
No
Are you legally eligible to work in the United States? (Proof of eligibility is required)
(required)
Yes
No
Applicants considered for hire will be subject to a background screening process that includes a criminal background check and a motor vehicle check. Please check if in agreement:
(required)
Yes
No
Date of Birth
(required)
(Numeric Answer Only)
Social Security Number
(required)
(Numeric Answer Only)
Are you Covid 19 vaccinated?
(required)
Yes
No
Section 2 -
Availability
Daytime - Hourly
(required)
Yes
No
Evening - Hourly
(required)
Yes
No
Overnight - Hourly
(required)
Yes
No
Live in
(required)
Yes
No
Saturday
(required)
Yes
No
Sunday
(required)
Yes
No
Please tell us what specific days and times you are available:
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Section 3 -
Educational Background
Type of School (High School/GED/College)
(required)
Name/City
(required)
How Many Years Attended
(required)
-- Select an Option --
1
2
3
4
Graduated
(required)
Yes
No
Section 4 -
1st Most Recent Employer
Employer:
(required)
Address:
(required)
City:
(required)
State:
(required)
Zip Code:
(required)
Start Date:
(required)
End Date:
Hours Worked:
(required)
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
(required)
Summarize the nature of the work performed and job responsibilities:
(required)
Show Plain Text
Supervisor's Name/Title:
(required)
Supervisor's Phone:
(required)
Reason for Leaving:
(required)
Show Plain Text
May we contact?
(required)
Yes
No
Hourly Rate Starting:
(required)
Hourly Rate Ending:
(required)
Section 5 -
2nd Most Recent Employer
Employer:
Address:
City:
State:
Zip Code:
Start Date:
End Date:
Hours Worked:
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
Summarize the nature of the work performed and job responsibilities:
Show Plain Text
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Hourly Rate Starting:
Hourly Rate Ending:
Section 6 -
3rd Most Recent Employer
Employer:
Address:
City:
State:
Zip Code:
Start Date:
End Date:
Hours Worked:
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
Summarize the nature of the work performed and job responsibilities:
Show Plain Text
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Hourly Rate Starting:
Hourly Rate Ending:
Section 7 -
Reference 1
Name:
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 8 -
Reference 2
Name:
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 9 -
Reference 3
Name:
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 10 -
Emergency Contact
Name:
(required)
Telephone:
(required)
Relationship:
(required)
Section 11 -
Notes
Anything else you would like to let us know:
Show Plain Text
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.
Signature
Submit Application