Date: 9/17/2014

Application Form

Franchise 546

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 - General Information

Number Question Effective Date Expiration Date
1 How did you hear about Comfort Keepers? (required)  
     
2 Which position are you applying for? CNA or Caregiver (required)  
     
3 Do you have a high school diploma or GED? (required)  
     
4 Are you 18 years old or older?  
     
5 Starting pay for CNA is $9.25-$9.50. Starting pay for caregiver is $8.00. Is this pay acceptable? (required)  
     
6 Have you ever been convicted of, pled guilty to, or pled no contest to a crime, excluding misdemeanors and traffic violations? (required)  
     
7 Have you had more than 3 traffic tickets in the last 7 years? (required)  
     
8 If you answered yes to having traffic violations, please explain.:  
 
9 Are you willing to participate in pre-employment and periodic drug screening? (required)  
     
10 We require that you pay $75 to help cover the cost of background screenings. Are you willing to pay $75? (required)  
     
11 You must have a dependable automobile & auto insurance. Do you have a safe automobile, carry auto insurance & a license? (required)  
     
12 We cannot guarantee hours due to the nature of the work. Is that acceptable? (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.