Employment Application
An Equal Opportunity Employer
Email address *
Today's Date *
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Name (First, Last, Middle) *
Your answer
Street Address *
Your answer
City, State, Zip Code *
Your answer
Phone Number *
Your answer
Are you eligible to work in the USA? *
Are you over 18 years of age? *
Are you currently employed? *
If yes, may we contact your current employer? *
What Comfort Care branch office are you applying for? *
Position for which you are applying. *
Your answer
Start Date: *
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Desired Pay: *
Your answer
Employment Desired: *
How did you hear about this opening? *
Your answer
Availability (Please check all you are available) *
Required
School Name #1 (Please include name & address.) *
Your answer
Years Attended School #1: *
Your answer
Degree Received from School #1 *
Your answer
Major at School #1
Your answer
School Name #2 (Please include name & address.)
Your answer
Years Attended School #2
Your answer
Degree Received from School #2
Your answer
Major at School #2
Your answer
Other Education
Your answer
Years Attended Other Education
Your answer
Former Employer #1 (Name & Address) *
Your answer
Starting Month & Year at Employer #1 *
Your answer
Ending Month & Year at Employer #1 *
Your answer
Job Title at Employer #1 *
Your answer
Starting Pay Rate at Employer #1 *
Your answer
Ending Pay Rate at Employer #1 *
Your answer
Former Employer #2 (Name & Address) *
Your answer
Starting Month & Year at Employer #2 *
Your answer
Ending Month & Year at Employer #2 *
Your answer
Job Title at Employer #2 *
Your answer
Starting Pay Rate at Employer #2 *
Your answer
Ending Pay Rate at Employer #2 *
Your answer
Former Employer #3 (Name & Address) *
Your answer
Starting Month & Year at Employer #3 *
Your answer
Ending Month & Year at Employer #3 *
Your answer
Job Title at Employer #3 *
Your answer
Starting Pay Rate at Employer #3 *
Your answer
Ending Pay Rate at Employer #3 *
Your answer
Former Employer #4 (Name & Address) *
Your answer
Starting Month & Year at Employer #4 *
Your answer
Ending Month & Year at Employer #4 *
Your answer
Job Title at Employer #4 *
Your answer
Starting Pay Rate at Employer #4 *
Your answer
Ending Pay Rate at Employer #4 *
Your answer
Reference #1 (Please list Name, Phone Number, Company for which they work & Title.) *
Your answer
Reference #2 (Please list Name, Phone Number, Company for which they work & Title.) *
Your answer
Reference #3 (Please list Name, Phone Number, Company for which they work & Title.) *
Your answer
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Comfort Care Medicare, Inc. to verify their accuracy and to obtain reference information on my work performance. I hereby release Comfort Care Medicare, Inc. from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies and procedures of Comfort Care Medicare, Inc. However, I further understand that neither the policies/procedures of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or Comfort Care may terminate my employment at any time with or without notice or cause. *NAME typed below will be considered digital signature. *
Your answer
Date Signed: *
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