Date: 7/29/2014

Application Form

Franchise 381

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.

PLEASE SELECT THE OFFICE CLOSEST TO YOUR HOME:

Lakeland Office:  Lakeland, Mulberry, Polk City

Winter Haven Office:  Auburndale, Bartow, Davenport, Dundee, Frostproof, Ft. Meade, Haines City, Indian Lake Estates, Lk. Alfred, Lk. Wales, Winter Haven, Clermont

Sebring:  Avon Park, Lk. Placid, Okeechobee, Sebring, Wauchula

Office Location

Select Office Location:

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1 Are you currently employed? (required)  
     
2 Are you at least 20 years old? (required)  
     
3 Do you have the physical ability to lift, push, and pull up to 25 pounds? (required)  
     
4 Which position are you applying for? (required)  
 
 
 
 
5 Starting pay for Home Health Aide is $9.27/hour. Starting pay for caregiver is $8.25/hour. Live-in shifts are paid at a daily rate of $120 (not hourly). Is this pay acceptable? (required)  
     
6 Do you have a high school diploma or GED? (required)  
     
7 Why do you want to work here? (required)  
     
8 Tell me about your caregiving work experience. (required)  
 
9 We cannot guarantee hours due to the nature of the work. Is that okay? (required)  
     
10 What is the ideal number of hours you want to work each week? (required)  
  (Numeric Answer Only)    
11 What days of the week are you available to work? (required)  
     
12 What shift do you prefer to work? (required)  
 
 
 
 
 
13 Please specify any scheduling issues here:  
 
14 We will train for Home Health Aide, but this training is optional and we do not pay for this training. This is not a CNA course, and you will not receive a state license or certificate. Are you interested in becoming a NON-LICENSED Home Health Aide? (required)  
     

Section 2 - Pre-Hire Requirements

Number Question Effective Date Expiration Date
1 We do extensive background checks. Do you have an ARREST record (convicted or not) or CRIMINAL record that may show up on the county, state, or federal levels? (required)  
     
2 If you answered "Yes" to question #1, please explain in the box below. If you answered "no," please simply type N/A. (required)  
 
3 You will be required to participate in biometric fingerprinting as required by the State of Florida. Are you willing to get fingerprinted as part of the hiring process? (required)  
     
4 We require that you pay $50 UP FRONT to help cover the cost of state background checks. Are you willing to pay the $50 to get registered for fingerprinting? (required)  
     
5 You must have a dependable automobile, auto insurance, and valid driver's license. Do you have YOUR OWN safe automobile? (required)  
     
6 Do you have a valid driver's license? (required)  
     
7 Do you have proof of valid auto insurance in YOUR name? (required)  
     
8 Do you have any moving violations (speeding tickets, DUI, reckless driving, etc) on your driving record? (required)  
     
10 If you answered yes to traffic violations, please explain: (required)  
 
11 We check all employees within 3 days of hire of their legal right to work in the United States through E-Verify. Do you have the LEGAL right to work in the U.S.? (required)  
     
12 All employees are checked for criminal activity through the national database Acxiom prior to inviting to orientation. Are you willing to submit to this pre-hire inquiry? (required)  
     
13 All Home Health Aides must be willing to obtain a health statement from a physician of choice. Are you willing to obtain a health statement for employment with the agency? (required)  
     
14 Florida Statutes requires caregivers working in the home to maintain a current CPR card at all times. Do you hold a current CPR card? (Answering (required)  
     
15 We require a drug screening prior to pairing with a client. Are you willing to take a drug test? (required)  
     

Section 3 - Referral Source

Number Question Effective Date Expiration Date
1 How did you hear about Comfort Keepers? (required)  
     
2 Who may we thank for the referral?  
     
3 Have you ever worked for this company before? (required)  
     
4 Please list three references (name, valid phone, and relationship) here. Indicate whether the reference is PERSONAL or PROFESSIONAL. Please do NOT list your family members, including siblings, spouse, parents, etc. (required)  
 

Section 4 - WORK HISTORY-List your Last 3 Employers

Number Question Effective Date Expiration Date
1 Employer- Most Recent (required)  
     
2 Street Address, City, State, Zip (required)  
     
3 Current Phone number or Valid fax number: (required)  
     
4 Dates Employed: (required)  
     
5 Please summarize the nature of the work performed: (required)  
 
6 Reason For Leaving? (required)  
 
7 Rate of pay? (required)  
  (Numeric Answer Only)    
8 Job Title (required)  
     
9 Direct Supervisor: (required)  
     
10 May we contact this Employer? (required)  
     
11 Employer-Next Recent (required)  
     
12 Street Address, City, State, Zip Code (required)  
     
13 Current Phone Number or Valid Fax Number (required)  
     
14 Dates Employed (required)  
     
15 Please summarize the nature of the work performed (required)  
 
16 Reason for Leaving (required)  
     
17 Rate of Pay (required)  
     
18 Job Title (required)  
     
19 Direct Supervisor (required)  
     
20 May we Contact this Employer? (required)  
     
21 Employer (required)  
     
22 Street Address, City, State, Zip Code (required)  
     
23 Current Phone Number or Valid Fax Number (required)  
     
24 Dates Employed (required)  
     
25 Please summarize the nature of the work performed (required)  
 
26 Reason for Leaving (required)  
     
27 Rate of Pay (required)  
     
28 Job Title (required)  
     
29 Direct Supervisor (required)  
     
30 May we Contact this Employer? (required)  
     

Section 5 - EDUCATION

Number Question Effective Date Expiration Date
1 What is your highest level of education completed? (required)  
 
 
 
 
 
2 Do you have experience with Alzheimers Disease? (required)  
     
3 Do you have experience working with or around the senior population or disabled adults? (required)  
     
4 If you answered yes to questions 2 and/or 3, please elaborate on your experience:  
 
5 Are you a current, licensed CNA? (required)  
   
6 If you answered yes, to question # 5, please tell us where you were trained? (required)  
     
7 If you answered question # 6, please tell us the length of your CNA training? (required)  
     

Section 6 - ELECTRONIC SIGNATURE

Number Question Effective Date Expiration Date
1 By electronically signing this application, I certify that the information that is voluntarily offered in this application is true and correct to the best of my knowledge. I understand that providing false information for the purpose of securing employment is against the law. If you agree, please type your name below: (required)  
     
2 Date of Application:  
     



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.