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Employment Application

Application for Employment

APPLICATION: Fill out and submit the application on this page

Important: You are not able to save your work. Be sure to set aside enough uninterrupted time to complete the application. It may take over 20 minutes to finish the application.

Personal Information

How did you learn about us?
If Relative, Friend, or Other
Salutation	Mr. Mrs. Ms. Miss
First Name
Middle Initial
Last Name
Address 1
Address 2
City
State	Two letter abbreviation such as PA, OH, NY
Zip
Social Security #
Phone	999-999-9999
Cell	999-999-9999
Email
May we contact your current employer?	(N/A, Yes, No)
Can you lawfully work in the USA?	(Yes, No) Yes indicates you are not prevented from lawfully becoming employed in this country because of Visa or Immigration Status. Proof of citizenship or immigration status will be required upon employment.
Date available to start	MM/DD/YYYY
What is your desired salary range?	dollars per hour

Employment History - Employer 1

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. Any, or all, of these employers may be contacted to verify employment information.

Employer
Address 1
Address 2
City
State	Two letter abbreviation such as PA, OH, NY
Zip
Phone	999-999-9999
Fax	999-999-9999
Job Title
Supervisor
Reason for Leaving
Start Date	MM/DD/YYYY
End Date	MM/DD/YYYY
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary

Employer 2

Employer
Address 1
Address 2
City
State	Two letter abbreviation such as PA, OH, NY
Zip
Phone	999-999-9999
Fax	999-999-9999
Job Title
Supervisor
Reason for Leaving
Start Date	MM/DD/YYYY
End Date	MM/DD/YYYY
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary

Employer 3

Employer
Address 1
Address 2
City
State	Two letter abbreviation such as PA, OH, NY
Zip
Phone	999-999-9999
Fax	999-999-9999
Job Title
Supervisor
Reason for Leaving
Start Date	MM/DD/YYYY
End Date	MM/DD/YYYY
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary

High School

School Name
School Address
Course of Study
Dates of Attendance	MM/YYYY - MM/YYYY
Diploma/Degree Received?	(Yes, No) If GED received, mark 'Yes'

Undergraduate College

School Name
School Address
Course of Study
Dates of Attendance	MM/YYYY - MM/YYYY
Diploma/Degree Received?	(Yes, No)

Graduate Professional

School Name
School Address
Course of Study
Dates of Attendance	MM/YYYY - MM/YYYY
Diploma/Degree Received?	(Yes, No)

Other Education (Specify)

School Name
School Address
Course of Study
Dates of Attendance	MM/YYYY - MM/YYYY
Diploma/Degree Received?	(Yes, No)

Professional Credentials

Certified Nurses Aide Expiration Date	MM/DD/YYYY
Certified Home Health Aide Expiration Date	MM/DD/YYYY
CPR Expiration Date	MM/DD/YYYY
First Aid Expiration Date	MM/DD/YYYY
Specialized Training	Describe any specialized training, apprenticeship, skills and extracurricular activities
Second Languages or other qualifications	Describe any other languages or any special qualifications for the position applied for

Additional Information

Do you have a VALID drivers license?	(Yes, No)
Drivers License Number
Drivers License State	Two letter abbreviation such as PA, OH, NY
Do you have RELIABLE transportation?	(Yes, No)
What transportation?
If needed, do you have RELIABLE child care?	(Yes, No, N/A)

Work Availability - Help Your Scheduler Get to Know You!

For each day, enter the start and end times when you are available to work (examples: none, 8a-5p, etc.). You may enter more than one period per day (example: 9:30a - 2:30p and 11p-7a) if you are available either or both of those periods.

Monday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p
Tuesday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p
Wednesday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p
Thursday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p
Friday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p
Saturday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p. Weekends can be alternated (i.e. every other weekend)
Sunday Times	Availability examples: none, 8a-5p, 7a-2p and 6p-10:30p. Weekends can be alternated (i.e. every other weekend)
Total Hours Per Week	How many hours per week would you like to work?

Work Expectations

Driving to Clients	Are you willing to drive to clients at a distance? (Yes, No)
Shift Length	Are you willing to work short shifts? (Yes, No)
Split Shifts	Are you willing to work split shifts? (Yes, No)
Allergies	Do you have any allergies we should be aware of (e.g. cat, dog, smoke, etc.)
Personal Accommodations	Are there any personal issues that need to be accommodated? (spouse's work schedule, school schedule, etc.)

Criminal Record Check

A CRIMINAL HISTORY CHECK IS MANDATORY FOR ALL APPLICANTS and requires maiden name, aliases, and date of birth information.

Have you ever plead guilty to, or been convicted of, any felony or misdemeanor?	(Yes, No) Exclude summary offenses
If yes, explain in detail
Maiden Name or Aliases (if any)
Date of Birth	MM/DD/YYYY

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted as that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I, hereby consent, that all outstanding debts owed to Comfort Care & Resources, Inc. may be deducted from any paycheck, including paychecks received after termination of employment.

Signature of Applicant	By entering your full name here, you certify that all statements on this application are true and complete.

When the application is complete, click Submit Employment Application .