Franchises 952 and 953 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
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Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
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Northern Mariana Islands
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Utah
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Zip
*
Driver's License Number
--
AL
AK
AS
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AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
AA
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AP
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MS
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AB
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MB
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NL
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NS
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ON
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QC
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YT
Section 1 -
General Information
What days and hours are you NOT available for work?
Have you previously worked at Comfort Keepers?
Yes
No
If so, When?
Are you legally eligible to work in the United States? (Proof of eligibility is required)
Yes
No
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, and may include a credit check, motor vehicle check and drug screen. (Please note that some positions require you to be insured and bonded.) Please check if in agreement:
Yes
No
Do you have reliable transportation to and from work and for travel between worksites, if required?
Yes
No
Do you have any relatives currently employed by Comfort Keepers?
Yes
No
If yes, please list:
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?
Yes
No
If no, describe the functions that cannot be performed:
Section 2 -
Educational Background
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
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:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
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:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
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:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
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