Caregiver Employment Application Form

PERSONAL INFORMATION
Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Phone Number*
Business Phone
Cellphone
Please list age (if under 18):
Please list age (if under 18):
Position applied for:*
Have you ever applied here before?
Salary range desired:*

Please indicate the days and times you are available to work: *

	From	To
Mon
Tue
Wed
Thr
Fri
Sat
Sun

How many hours can you work weekly?
Are you available to work nights?
Are you available to work weekends?
Would you consider live-in?
Employment desired:

Part-time onlyFull or Part-timeFull-time only
Are you legally authorized to work in the US?

YesNo
When are you available to start work?
Where did you hear about us?
Email
example@example.com
EDUCATION INFORMATION

	NAME OF SCHOOL	LOCATION (City, State)	NUMBER OF YEARS COMPLETED	MAJOR & DEGREE
High School
College
Bus. Or Trade School
Professional School

Have you ever been convicted of a crime?
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):
Have you ever worked under a different name?
If YES, what was it and what was the reason?
Do you have any relatives or friends that work for the Company?
If YES, what is their name?
In Case of Emergency, please contact:*
CERTIFICATIONS AND CREDENTIALS

Please check all that apply, and enter the expiration date and any notes as applicable.

	Active	Expiration Date	Notes
Car Insurance
Chest X-Ray
CNA License
CPR Certification
Driver's License
First Aid Certification
HHA Certification
LVN/LPN Certification
Registered Nurse
Tuberculosis Test

MATCH CRITERIA

Please select checkboxes that match your skills and preferences.
Max client weight for transfers:

DRIVING INFORMATION
Do you have a driver’s license?
Do you have active auto insurance?
Do you have a car?
If NO, How would you get to work?
Driver’s License No.:
State of Issue:
Expiration Date:
PERSONAL REFERENCE INFORMATION

List two personal references. DO NOT LIST relatives or previous supervisors.
1. Name
Relationship
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone where person can be reached 9a – 5p
Please enter a valid phone number.
2. Name
Relationship
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone where person can be reached 9a – 5p
Please enter a valid phone number.
An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications to be a caregiver. Please note any experience with caregiving professionally, for your parents, spouse, children or friends. Use additional sheets, if necessary.
Why do you enjoy caregiving?
Describe some of your volunteer work:

__________________________________________________________________________________________

PLEASE READ CAREFULLY
__________________________________________________________________________________________

APPLICATION FORM WAIVER
Page 4 of 4

In exchange for the consideration of my job application by Comfort Caregivers & Home Care (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Personal Care Services, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and Comfort Caregivers & Home Care may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
Signature*

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Date*

MonthDayYear
Date
Printed Name*
Comfort Caregivers & Home Care is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Please return this application to our office at your earliest convenience.

(PLEASE PRINT OR TYPE)

I, the undersigned consumer, do hereby authorize Comfort Caregivers & Home Care by and through its independent contractor, ADP, to procure a consumer report and/or investigative consumer report on me.

These above-mentioned reports may include, but are not limited to, information as to my character, general reputation, personal characteristics and mode of living, discerned through employment and education verifications; personal references; personal interviews; my personal credit history (if applicable to the position) based on reports from any credit bureau; my driving history, including any traffic citations; a social security number verification; present and/or former addresses; criminal and/or civil history/records; or any other public record.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request to ADP, if such is made within a reasonable time after the date hereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. § 1681et. seq.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to Comfort Caregivers & Home Care, by and through ADP, including, but not limited to, any and all courts, public agencies, law enforcement agencies and credit bureaus, regardless of whether such person, business entity or governmental agency compiled the information itself or received it from other sources.

I hereby release Comfort Caregivers & Home Care , ADP and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, by me, my heirs or others making such claim or demand on my behalf, for providing a consumer report and/or investigative consumer reporthereby authorized.

I understand that this Authorization/Release form shall remain in effect for the duration of my employment with said Company. Additionally, I give permission to investigate any incidents of workplace misconduct, including but not limited to; sexual harassment, of which I have been accused for which I am alleged to have been involved during my employment. Further, I certify that the information contained on this Authorization/Release form is true and correct and that my application or employment may be terminated based on any false, omitted, altered or fraudulent information.
Signature*

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Date*

MonthDayYear
Date
Printed Name
Other Names Used (Alias, maiden, nickname, etc.)
Date Used:

MonthDayYear
Date
Addresses:
Social Security Number:
Daytime Telephone Number:
Driver’s License Number:
State of Issuance:
Date of Birth:
Gender:
Have you ever been convicted of a crime or convicted in a military court martial?
Have you ever been sanctioned or had your licenses suspended or revoked?
Are you currently under any investigation or pending charge?
*This information will enable us to properly identify you in the event we find adverse information during the course of our background search.
Should be Empty:

	From / Start	To / Final
Employment Dates
Pay or Salary

	From / Start	To / Final
Employment Dates
Pay or Salary

	1	2	3	4
Companionship
Meal Preparation
Light Housekeeping
Bathing / Showering
Dressing / Grooming
Transferring
Incontinence Care
Dementia / Alzheimer’s Care