Comfort Keepers Employment Application

Carefully and accurately fill out all fields. When ready, click "Submit" below.
1. Social Security Number
2. How did you hear about Comfort Keepers?
3. What interests you in working for Comfort Keepers?
4. Have you had experience working with the elderly or disabled?
Yes No
5. If yes, please describe your work experience.
6. If you have not worked with the elderly or disabled, have you taken care of elderly or disabled friends or family members?
Yes No
7. If yes, please describe your experience.
8. Are you interested in full time, part time or seasonal work?
9. What days and hours (days, evenings, weekends) are you available to work?
10. If you are currently employed, where and what hours/days?
11. We may require you to work weekends and/or holidays. Can you do that?
Yes No
12. Are you available for overnight work?
Yes No
13. Are you available for assignments living at client's homes?
Yes No
14. Sometimes it takes a while to find the right job for someone. Do you need to start working immediately?
Yes No
15. Do you have a valid driver's license?
Yes No
16. We will conduct a driving background check. Have you had any points, tickets or suspensions?
Yes No
17. If yes, please describe.
18. Do you have a reliable car with auto insurance?
Yes No
19. How many minutes are you willing to drive one way to an assignment?
20. We will conduct a criminal background check. Have you ever plead guilty or been convicted of a crime?
Yes No
21. Can you supply documentation that proves you are legally eligible to work in the United States?
Yes No
22. Can you lift up to 25 pounds with or without reasonable accomodations?
Yes No
23. Do you enjoy cooking and meal planning?
Yes No
24. Are you a high school graduate or equivalent?
Yes No
25. Did you graduate college?
Yes No
26. College name and course of study
27. Any other business, trade school or certifications?
28. Please list your most recent employer name and address.
29. What was your job title?
30. Dates of employment and hourly rate.
31. Summarize the nature of the work performed and job responsibilities.
32. Reason for leaving.
33. Name and phone number of your immediate supervisor.
34. May we contact for verification?
Yes No
35. Please list your second most recent employer name and address.
36. What was your job title?
37. Dates of employment and hourly rate.
38. Summarize the nature of the work performed and job responsibilities.
39. Reason for leaving.
40. Name and phone number of your immediate supervisor.
41. May we contact for verification?
Yes No
42. Please list your third most recent employer.
43. What was your job title?
44. Dates of employment and hourkly rate.
45. Summarize the nature of the work performed and job responsibilities.
46. Reason for leaving.
47. Name and phone number of your immediate supervisor.
48. May we contact for verification?
Yes No
49. First personal reference name and phone number.
50. Relationship and years known.
51. Second personal reference name and phone number.
52. Relationship and years known.
53. Third personal reference name and phone number.
54. Relationship and years known.
55. If you have a license, what type (for example, CHHA, CNA, RN)?
56. If you have a license, what authority or board issued your license (for example, Board of Nursing, Dept of Consumer Affairs)
57. If you have a license, what is the license number and expiration date?
58. I hereby authorize Comfort Keepers to request and receive from all prior employers within one year of the date of this
Yes No
59. application, all pertinent information concerning my prior employment and its termination including the reasons for termination.