Franchise 3002 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
What position are you applying for: Personal Support Worker, Office Administration, Other
Where did you hear about Comfort Keepers?
What languages do you speak?
Are you a certified Personal Support Worker?
Yes
No
What days and hours are you NOT available for work?
Have you previously worked at Comfort Keepers?
Yes
No
Are you legally eligible to work in Canada?
Yes
No
Do you have a current (within 1 year) Criminal Record Check?
Yes
No
Do you have reliable transportation to and from work, as well as between clients?
Yes
No
Section 2 -
Educational Background
High School
Name/City
How Many Years Attended
-- Select an Option --
1
2
3
4
Graduated
Yes
No
College
Name/City
How Many Years Attended
-- Select an Option --
1
2
3
4
Graduated
Yes
No
Course
Section 3 -
1st Most Recent Employer
Employer:
Address:
City:
Start Date:
End Date:
Hours Worked:
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
Summarize the nature of the work performed and job responsibilities:
Show Plain Text
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Section 4 -
2nd Most Recent Employer
Employer:
Address:
City:
Start Date:
End Date:
Hours Worked:
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
Summarize the nature of the work performed and job responsibilities:
Show Plain Text
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Section 5 -
Reference 1
Name:
Telephone:
Years Known:
Relationship:
Section 6 -
Reference 2
Name:
Telephone:
Years Known:
Relationship:
Section 7 -
Reference 3
Name:
Telephone:
Years Known:
Relationship:
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