Employment Application
An Equal Opportunity Employer
Email address *
Today's Date *
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Name (First, Last, Middle) *
Street Address *
City, State, Zip Code *
Phone Number *
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. *
Start Date: *
MM
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DD
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YYYY
Desired Pay: *
Employment Desired: *
How did you hear about this opening? *
Availability (Please check all you are available) *
Required
School Name #1 (Please include name & address.) *
Years Attended School #1: *
Degree Received from School #1 *
Major at School #1
School Name #2 (Please include name & address.)
Years Attended School #2
Degree Received from School #2
Major at School #2
Other Education
Years Attended Other Education
Former Employer #1 (Name & Address) *
Starting Month & Year at Employer #1 *
Ending Month & Year at Employer #1 *
Job Title at Employer #1 *
Starting Pay Rate at Employer #1 *
Ending Pay Rate at Employer #1 *
Former Employer #2 (Name & Address) *
Starting Month & Year at Employer #2 *
Ending Month & Year at Employer #2 *
Job Title at Employer #2 *
Starting Pay Rate at Employer #2 *
Ending Pay Rate at Employer #2 *
Former Employer #3 (Name & Address) *
Starting Month & Year at Employer #3 *
Ending Month & Year at Employer #3 *
Job Title at Employer #3 *
Starting Pay Rate at Employer #3 *
Ending Pay Rate at Employer #3 *
Former Employer #4 (Name & Address) *
Starting Month & Year at Employer #4 *
Ending Month & Year at Employer #4 *
Job Title at Employer #4 *
Starting Pay Rate at Employer #4 *
Ending Pay Rate at Employer #4 *
Reference #1 (Please list Name, Phone Number, Company for which they work & Title.) *
Reference #2 (Please list Name, Phone Number, Company for which they work & Title.) *
Reference #3 (Please list Name, Phone Number, Company for which they work & Title.) *
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. *
Date Signed: *
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