Franchise 481 Application Form
Application Form
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.
Personal Information
First Name
*
Last Name
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
State
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District of Columbia
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Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
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Zip
*
Driver's License Number
--
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
AA
AE
AP
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MS
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OH
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VT
VI
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Section 1 -
Required Certificates
We are enrolled in certain programs that require extra credentials above the normal Florida standard. Please select "Yes" to acknowledge and proceed.
(required)
Yes
No
Have you had a physical exam for employment within the last 6 month?
(required)
Yes
No
Do you have AIDS/HIV/OSHA (Florida) certification?
(required)
Yes
No
Do you have Alzheimers Level 1 or 2 (Florida) certification?
(required)
Yes
No
Do you have Assist client with self administered meds certification?
(required)
Yes
No
Do you have a CPR certificate?
(required)
Yes
No
Do you have a HIPAA certificate?
(required)
Yes
No
Please either text your certificates to 954-920-0055 OR email them to yolandamiller@comfortkeepers.com
Yes
No
Section 2 -
General Information
How did you hear about us?
(required)
Are you currently employed?
(required)
Yes
No
Do you have the physical ability to lift, push, and pull up to 25 pounds?
(required)
Yes
No
Which position are you applying for?
(required)
-- Select an Option --
Home Health Aide
CNA
Companion
Have you previously worked at Comfort Keepers?
(required)
Yes
No
If so, When?
Are you legally eligible to work in the United States? (Proof of eligibility is required)
(required)
Yes
No
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, and may include a credit check, motor vehicle check and drug screen. Please check if in agreement:
(required)
Yes
No
Do you have reliable transportation to and from work and for travel between worksites, if required?
(required)
Yes
No
Do you have your own safe automobile and auto insurance?
(required)
Yes
No
What days of the week are you available to work?
(required)
What shift do you prefer to work? (Times may vary depending on the customer)
(required)
-- Select an Option --
Days (range 7am - 6pm)
Evenings (range 2pm - 7pm)
Nights (range 7pm - 7am)
Weekends (Sat & Sun)
Please specify any scheduling issues here:
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Comfort Keepers requires mandatory ONLINE training (a minimum of 12-14 hours) to meet the national standard. This is separate from the state of Florida required training. Are you willing to complete this mandatory ONLINE training prior to employment with us?
(required)
Yes
No
Section 3 -
Educational Background
What is your highest level of education completed?
(required)
-- Select an Option --
Grade School or incomplete High School
High School Graduate or Holds GED
Technical/Vocational School
Some College coursework - incomplete/non-graduated
College Graduate
Do you have experience working with persons afflicted with Alzheimers Disease?
(required)
Yes
No
Do you have have experience working with or around the senior population or disabled adults?
(required)
Yes
No
If you answered yes to questions 2 and/or 3, please describe your experience:
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Are you a current, licensed CNA or HHA?
(required)
Yes
No
If you answered yes to question 5, please tell us where you trained and the length of your training:
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What languages do you speak, read, or write fluently?
(required)
Show Plain Text
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.
Signature
Submit Application