Comfortcare Homehealth Services

Personal Information

Position *

Application Date *

Full Name *

Street Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Authorized to work in the United States *

Yes No

Sponsorship needed *

Yes No

Previously worked or applied with Comfortcare *

Yes No

If yes, when

Education

School	Degree	Major	Graduation Date or Status

Employment History

Most Recent 3 Employers

Employer 1

Employer Name *

Job Title *

Employment Dates *

Supervisor Name and Phone *

Reason for Leaving *

Employer 2

Employer Name

Job Title

Employment Dates

Supervisor Name and Phone

Reason for Leaving

Employer 3

Employer Name

Job Title

Employment Dates

Supervisor Name and Phone

Reason for Leaving

References

Reference 1

Name *

Relationship *

Phone Number *

Reference 2

Name

Relationship

Phone Number

Reference 3

Name

Relationship

Phone Number

Background / Certification

Have you been convicted of an unsealed crime *

Yes No

Explanation field

Can you perform the essential job functions *

Yes No

CPR Current *

Yes No

TB Current *

Yes No

Emergency Contact Name *

Emergency Contact Phone *

Applicant Certification

I certify the information is true and authorize verification. I understand employment is at will.

I agree to the certification statement.

Applicant Signature *

Signature Date *

Office Use Only

For Comfortcare office staff only.

Interview Date

Offer

Hire Date

Background Pass Pending

Drug Screen Pass

I 9 Yes

W 4 Yes

Employment Application

Employer 1

Employer 2

Employer 3

Reference 1

Reference 2

Reference 3

Downloadable Forms

New Client Info