Franchise 383 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.
Office Location
Select Office Location
-- Select Office --
Comfort Keepers Nashville
Comfort Keepers Knoxville
Comfort Keepers Chattanooga
Personal Information
First Name
*
Last Name
*
Social Security Number
*
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 -
Additional Information
Date of Birth (required for background check)
(required)
Section 2 -
General Information
What days and times are you available for work? (eg. Monday-Friday 7am-4pm)
(required)
When are you available to start?
(required)
Have you previously worked at Comfort Keepers?
(required)
Yes
No
If so, When?
Are you legally eligible to work in the United States? (Proof of eligibility is required)
(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:
(required)
Yes
No
Have you every been convicted of a crime, other then minor traffic violations?
(required)
Yes
No
If yes, please explain:
Do you have reliable transportation to and from work and for travel between worksites?
(required)
Yes
No
Do you have any relatives or friends currently employed by Comfort Keepers?
(required)
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?
(required)
Yes
No
If no, describe the functions that cannot be performed:
We require caregiver to be available to work one weekend per month, are you available to work one weekend per month?
(required)
Yes
No
Section 3 -
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 4 -
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 5 -
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 6 -
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 7 -
Reference 1
Name:
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 8 -
Reference 2
Name:
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 9 -
Reference 3
Name:
(required)
Telephone:
(required)
Years Known:
(required)
Relationship:
(required)
Section 10 -
Caregiver Attributes
Are you a smoker?
(required)
Yes
No
Do you have an active CNA or MA License?
(required)
Yes
No
Are you CPR or First Aide Certified?
(required)
Yes
No
Do you have a current TB skin test?
(required)
Yes
No
Can you work with a client who has Cats?
(required)
Yes
No
Can you work with a client who has dogs?
(required)
Yes
No
Can you work with a client who smokes?
(required)
Yes
No
Can you use a hoyer lift?
(required)
Yes
No
Can you use a transfer belt?
(required)
Yes
No
Can you handle incontinent care with a male client?
(required)
Yes
No
Can you handle incontinent care for a female client?
(required)
Yes
No
Do you know how to give a bed bath?
(required)
Yes
No
Are you able to shower a male client?
(required)
Yes
No
Are you able to shower a female client?
(required)
Yes
No
Are you willing to work with an end of life client?
(required)
Yes
No
Do you have experience with dementia?
(required)
Yes
No
Do you have experience with a client who has a catheter?
(required)
Yes
No
Can you preform light housekeeping?
(required)
Yes
No
Are you able to prepare and/or cook meals?
(required)
Yes
No
Can you use a transfer or slide board?
(required)
Yes
No
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