Franchise 556 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
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
Comfort Keepers is a non-medical in-home care company. We are not able to guarantee hours, but base your schedule upon your availability. Are you comfortable with a fluctuating schedule?
(required)
Yes
No
What is your pay rate expectation? Is this flexible?
(required)
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, and motor vehicle check. Please check if in agreement:
(required)
Yes
No
Have you ever been convicted of or plead guilty to a Felony?
(required)
Yes
No
If so, What for?
(required)
Have you ever been convicted of or plead guilty to a Misdemeanor?
(required)
Yes
No
If so, What for?
(required)
Do you have dependable transportation?
(required)
Yes
No
What is the Make and Model of your vehicle?
(required)
Who is your Auto Insurance company?
(required)
When does your Auto Policy Expire?
(required)
Are you available to work 11:00PM through 7:00AM?
(required)
Yes
No
Are you available to work 3:00PM through 11:00PM?
(required)
Yes
No
Are you available to work 7:00AM through 3:00PM?
(required)
Yes
No
Do you understand and agree to be available every other weekend to work?
(required)
Yes
No
Have you previously worked at Comfort Keepers?
(required)
Yes
No
If so, When?
What type of job schedule are you looking for?
(required)
-- Select an Option --
Full Time (30+ hours)
Part Time (15-30 hours)
On Call
Any
Comfort Keepers provides services to Vigo, Clay, Parke, Vermillion, Putnam and Sullivan Counties. We try to schedule everyone within a 30 mile radius of their homes. Are you comfortable traveling for this position?
(required)
Are you legally eligible to work in the United States? (Proof of eligibility is required)
(required)
Yes
No
Do you have any relatives currently employed by Comfort Keepers?
Yes
No
Do you have experience working with someone suffering from Dementia or Alzheimer's Disease?
(required)
Yes
No
Have you ever worked with someone who was on Hospice?
(required)
Yes
No
Would you consider working with someone that needs bathing assistance?
(required)
Yes
No
Would you consider working with someone that needs assistance toileting/incontinence?
(required)
Yes
No
Are you comfortable working with male clients?
(required)
Yes
No
Are you comfortable working with female clients?
(required)
Yes
No
Do you have experience working with a mechanical lift?
(required)
Yes
No
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?
(required)
Yes
No
If no, describe the functions that cannot be performed:
For contact purposes, who is your current cell phone provider (Ex.-Verizon, ATT, Sprint, Straight Talk)
(required)
Are you comfortable working around/with pets?
(required)
Yes
No
Are you comfortable working around/with smokers?
(required)
Yes
No
Section 2 -
Educational Background
Type of School (High School/GED/College)
(required)
Name/City
How Many Years Attended
-- Select an Option --
1
2
3
4
Graduated
(required)
Yes
No
Course or Major
Type of School (High School/GED/College)
Name/City
How Many Years Attended
-- Select an Option --
1
2
3
4
Graduated
Yes
No
Course or Major
Section 3 -
1st 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 4 -
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 5 -
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 6 -
Reference 1
Name:
Telephone:
Years Known:
Relationship:
Section 7 -
Reference 2
Name:
Telephone:
Years Known:
Relationship:
Section 8 -
Reference 3
Name:
Telephone:
Years Known:
Relationship:
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