It is the policy of ComfortCare Homes, Inc. to recruit and employ the best quaified personnel for available positions, to provide equal opportunity for the advancement of employees, and to administer these activities in a manner which will not discriminate against any person because of race, creed, color, religion, age sex, national origin, physical or mental handicap, economic status, or marital status.

Personal Information:
First Name: Middle Name: Last Name:
Home Phone: Alternate Phone:
Address: City: State: Zip:
Date Available for work: Desired Wage/Salary:
Hours: Full-Time Part-Time Relief
Have you ever worked under a different name? (for reference) Yes No If yes, name:
Have you ever worked for ComfortCare Homes before? Yes No If yes, when:
Any days/hours you can not work? Yes No If yes, when:
Are you legally eligible for employment in this country? Yes No  
Are you able to work week-ends? Yes No  
Have you had training in working with Memory Impared people? Yes No If yes, please explain:
Have you ever been convicted of a felony? Yes No If yes, please explain:
Hve you been convicted of an offense that involved abuse, neglect, or mistreating individuals? Yes No If yes, please explain:
How did you learn about this opportunity?
Please check all that apply:
RN LPN CMA CNA ACT
Employment History:
Start Date:
End Date:
Start $/hour:
Final $/hour:
Final Job Title:
Employer:
Immediate Supervisor:
Address:
Phone Number:
Reason for Leaving:
May we contact company? Yes No If no, please explain:
Start Date:
End Date:
Start $/hour:
Final $/hour:
Final Job Title:
Employer:
Immediate Supervisor:
Address:
Phone Number:
Reason for Leaving:
May we contact company? Yes No If no, please explain:
Start Date:
End Date:
Start $/hour:
Final $/hour:
Final Job Title:
Employer:
Immediate Supervisor:
Address:
Phone Number:
Reason for Leaving:
May we contact company? Yes No If no, please explain:
Education:
  Name and Location # of years Graduate? Course of study
Elementary School
Location (City & State)      
High School
Location (City & State)      
College
Location (City & State)      
Other
Location (City & State)      
References:
(Excluding former employers and relatives)
Name Phone Number Years Known City, State