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Employment Application

Please complete this application as completely and accurately as possible.

Personal Information

Prefix

First Name *

Middle Name

Last Name *

Todays date *

Street Address *

State *

ZIP CODE *

Country *

Social Security Number *

Are you over the age of 18? *

Cell Phone Number *

Are you a US Citizen? *

Home Phone Number *

If no, do you have the legal right and necessary documents to work in the US? *(Identity and employment eligibility will be verified as required by law.)

Nursing License # *

Email Address

Employment Information

Position Desired *

Shift Preference *

Salary Requirement *

Date available for work *

Do you possess a valid driver’s license? *

Driver’s License Number *

Do you have your own transportation? *

Have you applied here before? *

If so, when? *

How were you referred to us? *

Explain *

Qualifications & Experiences

EDUCATION

High School

Did you graduate?

College

Did you graduate?

Nursing School

Did you graduate?

Technical Training

Did you graduate?

Languages spoken in addition to English. *

Can you perform all of the job-related functions of the position(s) for which you are applying? *

If no, please explain:

Do you have current CPR certification? *

Expiration Date

Why do you want to work for this Comfort Care at Home, Inc.? *

Past and Present Employers

Current Employer

Name

Street Address

ZIP CODE

Phone

Date Started

Position

May we contact?

Salary

Supervisor

Name

Street Address

ZIP CODE

Phone

Date Started

Position

May we contact?

Salary

Supervisor

Past Employers:

Name

Phone

Street Address

ZIP CODE

Salary

May we contact your employer? *

Supervisor

Start Date

End Date *

Reason leaving

Name

Phone

Street Address

ZIP CODE

Salary

May we contact your employer? *

Supervisor

Start Date

End Date *

Reason leaving

Reference

Give work or medical field related references. Do not list relatives or personal friends.)

Name *

Phone *

Street Address *

ZIP CODE

Relationship *

Years Acquainted *

Criminal Background

Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime? *

If yes, please explain. Details:(You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.)

Emergency Contact

Name

Home Phone *

Work Phone

Street Address

ZIP CODE

Relationship to you *

“I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.”

I understand employment by this company does not constitute a contractual agreement. Employment is at-will and can be terminated by the company or myself at any time for any lawful reason with or without notice. We are an Equal Opportunity Employer (EOE). Qualified applicants are considered for employment without regard to age, race, color, sex, national origin, sexual orientation, disability, or veteran status.

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