Date: 7/22/2014

Application Form

Franchise 195

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 * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - APPLICANT DATA

Number Question Effective Date Expiration Date
1 Position Applied for: (required)  
     
2 Date Available to Start Work? (required)  
     
3 Type of Employment desired: (required)  
 
 
 
 
 
4 Are you able to work overtime if required? (required)  
     
5 Have you previously applied at Comfort Keepers? (required)  
     
6 If your answer to the question above was yes, what date did you last apply?  
     
7 Have you previously worked at Comfort Keepers? (required)  
     
8 If your answer to the question above was yes, what date did you last work at Comfort Keepers?  
     
9 Are you able to provide proof of eligibility to work in the United Status? (required)  
     
10 Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? (required)  
     
11 If your answer to question above was no, please describe the functions that cannot be performed.  
 
12 (Note: We comply with ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical exam and to skill and agility tests.) (required)  
 
13 Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (required)  
     
14 If Yes to 13 above, state nature of crime, when and where convicted and disposition of case. (Convictions for misdemeanor marijuana-related offenses that are more than 2 years old need NOT be listed) (required)  
 
15 If required for this position, do you have a valid driver's license (required)  
   
16 Confirm any prior DMV violations  
     
17 How did you hear about us? (required)  
 
 
 
 
 

Section 2 - EDUCATIONAL BACKGROUND

Number Question Effective Date Expiration Date
1 High School (required)  
 
 
 
2 Date above degree obtained?  
     
3 College Graduate  
 
 
 
 
4 Date above degree obtained?  
     
5 Business or Trade  
 
6 Date above degree obtained?  
     

Section 3 - EMPLOYMENT HISTORY

Number Question Effective Date Expiration Date
1 Most Recent Employer 1 - Company Name (required)  
     
2 Employer 1 - Street Address (required)  
     
3 Employer 1 - City (required)  
     
4 Employer 1 - State (required)  
     
5 Employer 1 - Zip Code (required)  
  (Numeric Answer Only)    
6 Employer 1 - Your Job Title (required)  
     
7 Employer 1 - Name of Immediate Supervisor (required)  
     
8 Employer 1 - Title of Immediate Supervisor (required)  
     
9 Employer 1 - Reason for leaving (required)  
     
10 Employer 1 - Start Date (required)  
     
11 Employer 1 - End Date (required)  
     
12 Employer 1 - Start Salary (Hourly) (required)  
  (Numeric Answer Only)    
13 Employer 1 - End Salary (Hourly) (required)  
  (Numeric Answer Only)    
14 Employer 1 - May we contact for reference/verification? (required)  
 
 
 
15 Employer 1 - Summarize the nature of the work performed and your job responsibilities: (required)  
 
16 Employer 2 - Company Name  
     
17 Employer 2 - Street Address  
     
18 Employer 2 - City  
     
19 Employer 2 - State  
     
20 Employer 2 - Zip Code  
  (Numeric Answer Only)    
21 Employer 2 - Your Job Title  
     
22 Employer 2 - Name of Immediate Supervisor  
     
23 Employer 2 - Title of Immediate Supervisor  
     
24 Employer 2 - Reason for Leaving  
     
25 Employer 2 - Start Date  
     
26 Employer 2 - End Date  
     
27 Employer 2 - Start Salary (Hourly)  
  (Numeric Answer Only)    
28 Employer 2 - End Salary (Hourly)  
  (Numeric Answer Only)    
29 Employer 2 - May we contact for reference/verification?  
 
 
 
30 Employer 2 - Summarize the nature of the work performed and your job responsibilities:  
 
31 Employer 3 - Company Name  
     
32 Employer 3 - Street Address  
     
33 Employer 3 - City  
     
34 Employer 3 - State  
     
35 Employer 3 - Zip Code  
  (Numeric Answer Only)    
36 Employer 3 - Your Job Title  
     
37 Employer 3 - Name of Immediate Supervisor  
     
38 Employer 3 - Title of Immediate Supervisor  
     
39 Employer 3 - Reason for Leaving  
     
40 Employer 3 - Start Date  
     
41 Employer 3 - End Date  
     
42 Employer 3 - Start Salary (Hourly)  
  (Numeric Answer Only)    
43 Employer 3 - End Salary (Hourly)  
  (Numeric Answer Only)    
44 Employer 3 - May we contact for reference/verification?  
 
 
 
45 Employer 3 - Summarize the nature of the work performed and your job responsibilities:  
 
46 Please provide any comments, skills, or qualifications below (including explaining any gaps in employment):  
 

Section 4 - REFERENCES

Number Question Effective Date Expiration Date
1 Reference 1 - Full Name (required)  
     
2 Reference 1 - Telephone Number (required)  
     
3 Reference 1 - Years Known (required)  
  (Numeric Answer Only)    
4 Reference 1 - Relationship (required)  
 
 
 
5 Reference 2 - Full Name (required)  
     
6 Reference 2 - Telephone Number (required)  
     
7 Reference 2 - Years Known (required)  
  (Numeric Answer Only)    
8 Reference 2 - Relationship (required)  
 
 
 
9 Reference 3 - Full Name (required)  
     
10 Reference 3 - Telephone Number (required)  
     
11 Reference 3 - Years Known (required)  
  (Numeric Answer Only)    
12 Reference 3 - Relationship (required)  
 
 
 

Section 5 - AVAILABILITY

Number Question Effective Date Expiration Date
1 Are you available to work on Mondays? (required)  
 
 
 
 
 
2 Are you available to work on Tuesdays? (required)  
 
 
 
 
 
3 Are you available to work on Wednesdays? (required)  
 
 
 
 
 
4 Are you available to work on Thursdays? (required)  
 
 
 
 
 
5 Are you available to work on Fridays? (required)  
 
 
 
 
 
6 Are you available to work on Saturdays? (required)  
 
 
 
 
 
7 Are you available to work on Sundays? (required)  
 
 
 
 
 

Section 6 - COMPANION CARE

Number Question Effective Date Expiration Date
1 Do you have the ability to prepare healthy meals? If so, give one healthy meal example. (required)  
     
2 Are you able to transfer between 25-40 pounds? (required)  
     
3 Are you willing to transport client? (required)  
     
4 Are you willing to perform light housekeeping? (required)  
     
5 Are you willing to work in a smoker's home? (required)  
     
6 Are you willing to work with client's pets (dogs, cats, birds, etc)? (required)  
     
7 Are you able to utilize computerized maps (MapQuest, Google Maps, etc.)? (required)  
     
8 Can you speak conversational English? (required)  
     
9 What do you like about caring for the elderly? (required)  
     
10 Are you willing to work in a multi-level home? (required)  
     
11 Are you willing to work with clients who have Dementia? (required)  
     
12 Are you willing to drive a client IN YOUR CAR while on the job? (required)  
 
 
 
13 Are you willing to drive the client’s car on the job? (required)  
 
 
 

Section 7 - CAREGIVING EXPERIENCE

Number Question Effective Date Expiration Date
1 Have you had a TB Test? (required)  
 
 
 
2 Date of most recent TB Test Results?  
     
3 Have you had Immunizations - MMR? (required)  
 
 
 
4 Date of Immunization-MMR?  
     
5 Have you had Immunization - V-Zoster? (required)  
 
 
 
6 Date of Immunization - V-Zoster?  
     
7 Have you had Immunization - Hep B? (required)  
 
 
 
 
8 Date of Immunization - Hep B?  
     
9 Do you have Live-Scan Fingerprints? (required)  
 
 
 
10 Date of Live-Scan Fingerprints?  
     
11 If you have any of the above reports, please list the name, address, and phone number of the facility that holds them:  
 
12 Do you have any other training or licensing, i.e, CPR? Please list: (required)  
     
13 Are you a C.N.A.? (required)  
     
14 How many "months" of experience do you have with lifting procedures? (required)  
  (Numeric Answer Only)    
15 How many "months" of experience do you have with transfers? (required)  
  (Numeric Answer Only)    
16 How many "months" of experience do you have with bed baths? (required)  
  (Numeric Answer Only)    
17 How many "months" of experience do you have with showering/bathing assistance? (required)  
  (Numeric Answer Only)    
18 How many "months" of experience do you have with feeding? (required)  
  (Numeric Answer Only)    
19 How many "months" of experience do you have with adult diapers/depends? (required)  
  (Numeric Answer Only)    
20 How many "months" of experience do you have with bed pans? (required)  
  (Numeric Answer Only)    
21 How many "months" of experience do you have with dementia? (required)  
  (Numeric Answer Only)    
22 How many "months" of experience do you have with Alzheimer's? (required)  
  (Numeric Answer Only)    
23 How many "months" of experience do you have with hospice care? (required)  
  (Numeric Answer Only)    

Section 8 - PERSONAL CARE

Number Question Effective Date Expiration Date
1 Are you willing to assist client with bathing and grooming? (required)  
     
2 Are you willing to change adult diapers/depends? (required)  
     

Section 9 - STANDARD INTERVIEW QUESTIONS

Number Question Effective Date Expiration Date
1 This job requires regular and reliable transportation. How would you meet this job requirement? (required)  
 
2 This job requires that you follow the chain of command and adhere to Company policies and procedures. Tell me what you would do in the following situations while working in a client’s home (start at question 3):  
     
3 A client or a client’s family member asks you to give an insulin injection: (required)  
 
4 It’s 8:30am, your shift starts at 9:00am, and your car won’t start. What would you do? (required)  
 
5 A client asks you to stay late or come early for your next shift: (required)  
 
6 The children of a client want you to perform a service outside of your job description/covered service: (required)  
 
7 Clients are often forgetful, think you are someone else, accuse you of wrong doing or get temperamental. How would you handle a difficult situation like this? (required)  
 
8 What qualities/attributes do you possess that you feel make you a good caregiver? (required)  
 
9 Why do you want to work for Comfort Keepers? (required)  
 



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.