Franchise 3202 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
*
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
*
Driver's License Number
--
AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
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
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VT
VI
VA
WA
WV
WI
WY
Section 1 -
General Information
Position(s) Applying For:
Date of Application
Referral Source:
-- Select an Option --
Advertisement
Employee
Relative
State Employment Agency
Other
Name: (Last, First, Middle)
(required)
Social insurance Number
(Numeric Answer Only)
Email Address
Current Street Address
City
State
postal code
How long at this address?
Previous Street Address
City
province
postal code
How long at this address?
Phone Number:
Cell Phone:
Best time to call you:
Section 2 -
Employment Information
What date are you available for Employment?
Type of employment desired (Type All that Apply) Full Time, Part Time, Temporary, Seasonal.
Are you able to work overtime, if required?
Yes
No
Are you able to meet the attendance requirements of the position?
Yes
No
Have you previously applied for a position at Comfort Keepers?
Yes
No
If Yes, then when?
Have you previously worked at Comfort Keepers?
Yes
No
If Yes, then when?
Are you eligible to work in the Canada? (Proof of eligibility will be required before you can be employed.)
Yes
No
Have you ever been convicted of/or plead guilty to a crime (other than minor traffic violations)?
Yes
No
If yes, please explain: (give date, location, charge, etc.) (Please note that in order to be hired by Comfort Keepers, you must be Bondable.)
If the job requires, do you have a valid drivers license?
Yes
No
DL#
(Numeric Answer Only)
Type:
province of Issue
Have you had any moving violations in the past 3 Years?
Yes
No
If yes, please describe:
Do you have any relatives currently employed by Comfort Keepers?
Yes
No
If yes, please list:
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?
Yes
No
If no, describe the functions that cannot be performed: (Note: we comply with the ADA and consider reasonable accommodations measure that may be necessary to eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)
Name of person to be contacted in case of an emergency (Last, First, Middle)
Relationship
Telephone Number
Address
City, province, postal code
Section 3 -
Education
Do you have a High School Diploma?
Yes
No
Name and City
How many years attended?
(Numeric Answer Only)
Graduate?
Yes
No
Course or Major
Do you have a College Degree?
Yes
No
Name and City
How many years attended?
(Numeric Answer Only)
Graduate?
Yes
No
Course or Major
Do you have a Graduate Degree?
Yes
No
Name and City
How many years attended?
(Numeric Answer Only)
Graduate?
Yes
No
Course or Major
Did you Attend Business or Trade School?
Yes
No
Name and City
How many years attended?
(Numeric Answer Only)
Graduate?
Yes
No
Course or Major
Other Education (Please Specify)
Section 4 -
Most Recent Employer
Employer
Start Date
End Date
Address
City, State, Zip
Phone Number
(Numeric Answer Only)
Starting Salary
(Numeric Answer Only)
Ending Salary
(Numeric Answer Only)
Job Title
Name of Supervisor
Reason(s) for Leaving:
Summarize the nature of the work performed and job responsibilities
Show Plain Text
Section 5 -
Second Most Recent Employer
Employer
Start Date
End Date
Address
City, State, Zip
Phone Number
(Numeric Answer Only)
Starting Salary
(Numeric Answer Only)
Ending Salary
(Numeric Answer Only)
Job Title
Name of Supervisor
Reason(s) for Leaving:
Summarize the nature of the work performed and job responsibilities
Show Plain Text
Section 6 -
Third Most Recent Employer
Employer
Start Date
End Date
Address
City, State, Zip
Phone Number
(Numeric Answer Only)
Starting Salary
(Numeric Answer Only)
Ending Salary
(Numeric Answer Only)
Job Title
Name of Supervisor
Reason(s) for Leaving:
Summarize the nature of the work performed and job responsibilities
Show Plain Text
Section 7 -
Other Employers and Comments
Comments and other Skills, licenses/certification and qualifications (including explanation of any gaps in employment)
Show Plain Text
Section 8 -
Professional References
Reference 1
Telephone Number
(Numeric Answer Only)
Years Known
(Numeric Answer Only)
Relationship
Reference 2
Telephone Number
(Numeric Answer Only)
Years Known
(Numeric Answer Only)
Relationship
Reference 3
Telephone Number
(Numeric Answer Only)
Years Known
(Numeric Answer Only)
Relationship
Section 9 -
Applicants Certification and Agreement
I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date.
(required)
Yes
No
I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Comfort Keepers other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s).
(required)
Yes
No
If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Comfort Keepers.
(required)
Yes
No
This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personnel file. If I am not hired or have not heard from this employer within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Comfort Keepers.
(required)
Yes
No
I give the employer and /or its agents, including consumer reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless this employer, its representatives, all persons and organizations/companies for furnishing such information.
(required)
Yes
No
If required, I agree to a drug testing prior and during employment or for post accident occurrences.
(required)
Yes
No
The employer, Comfort Keepers, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicants consideration for employment on a basis prohibited by local, state, or federal law.
(required)
Yes
No
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