Franchise 234 Application Form
Application Form
WELCOME TO COMFORT KEEPERS!
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
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
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
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
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
Gender
(required)
-- Select an Option --
Female
Male
Cellular Service Provider
(required)
Type of employment desired
(required)
-- Select an Option --
Part Time
Full Time
No Preference
Position Type: Long Hours Shifts
(required)
Yes
No
Position Type: Short Hours Shifts
(required)
Yes
No
Position Type: Come & Go
(required)
Yes
No
Position Type: Live-In
(required)
Yes
No
Position Type: Night Shifts Only
(required)
Yes
No
Position Type: Weekends Only
(required)
Yes
No
Position Type: Weekdays Only
(required)
Yes
No
Are you able to perform the essential functions of the job for which you are applying it may include bending, squatting, pushing or lifting up to 50 lbs.?
(required)
Yes
No
If No, please explain
Have you previously worked at Comfort Keepers?
Yes
No
Effective Date
Are you eligible to work in the United States? (Proof of eligibility will be required before you can be employed.)
(required)
Yes
No
If you have work authorization is it current?
(required)
Yes
No
I am 18 yrs of age or older
(required)
Yes
No
Were you referred to us by a Caregiver who is currently working with us?
(required)
Yes
No
If YES, please list their name
Are you a Family Preferred Caregiver?
(required)
Yes
No
If YES, for which client?
Our Payroll policy requires that pay be directly deposited. Are you willing to provide this information, should you be hired?
(required)
Yes
No
Section 2 -
Availability
Availability to work on Mondays (Enter Time From/To)
(required)
Availability to work on Tuesdays (Enter Time From/To)
(required)
Availability to work on Wednesdays (Enter Time From/To)
(required)
Availability to work on Thursdays (Enter Time From/To)
(required)
Availability to work on Fridays (Enter Time From/To)
(required)
Availability to work on Saturdays (Enter Time From/To)
(required)
Availability to work on Sundays (Enter Time From/To)
(required)
Section 3 -
Certifications
Do you have CNA certification?
(required)
Yes
No
Do you have LPN certification?
(required)
Yes
No
Do you have RN license?
(required)
Yes
No
Training certificates from another Home Care Agency?
(required)
Yes
No
Section 4 -
Emergency Information
Name of emergency contact
(required)
Relationship to you
(required)
Telephone of contact
(required)
Section 5 -
Educational Background
I have High School Diploma
(required)
Yes
No
I have GED Certificate
(required)
Yes
No
College Degree or Skilled Certification
(required)
Yes
No
Master's Level Degree or Higher
(required)
Yes
No
Section 6 -
1st Most Recent Employer
Employer:
(required)
City:
(required)
State:
(required)
Start Date:
(required)
End Date:
(required)
Number of hours worked per week:
(required)
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
Section 7 -
2nd Most Recent Employer
Employer:
City:
State:
Start Date:
End Date:
(required)
Number of hours worked per week:
(required)
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
Section 8 -
Personal Reference 1
Personal Reference Name (not family member):
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 9 -
Interview Questions
Tell me about your experiences as a caregiver:
(required)
Show Plain Text
What languages do you speak?
(required)
I have experience with: Hospice Care
(required)
Yes
No
I have experience with: Dementia Care
(required)
Yes
No
I have experience with: Hoyer Lift
(required)
Yes
No
I have experience with: Gait Belt
(required)
Yes
No
I have experience with: Bed Bound Clients
(required)
Yes
No
Have you ever cared for a family member (senior)?
(required)
Yes
No
Have you ever worked for Home Care Agency?
(required)
Yes
No
If YES where?
Have you ever worked for Senior Care Facility (Nursing Home/Rehab)?
(required)
Yes
No
If YES where?
I am a licensed and insured driver willing to drive clients:
(required)
Yes
No
I am wiling to work with: Male Clients
(required)
Yes
No
I am wiling to work with: Female Clients
(required)
Yes
No
I am wiling to work with: Cats
(required)
Yes
No
I am wiling to work with: Dogs
(required)
Yes
No
I am wiling to work with: Smokers
(required)
Yes
No
I have allergic reactions or allergies:
(required)
Yes
No
If YES please list:
Section 10 -
Applicant Signature
Print Caregiver Applicant Name:
(required)
Effective Date
*
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