Application Form

Driver's License Number

Date of Application: (required)

Referral Source: (required)

Referral Source Cont: If you were referred by Employee or Client please write thier name below

Name: (Last, First, Middle) (required)

Social Security Number: (required)

(Numeric Answer Only)

Date of Birth: (required)

Driver's License number and State (required)

Do you have current Auto Insurance under your name? (required)

Yes No

Did you receive a COVID Vaccine? If so which one? (required)

What date are you available to start employment? (required)

Have you previously worked for Comfort Keepers? (required)

Yes No

Do you have your own personal reliable vehicle to drive to and from work? As well as for travel between worksites? (required)

Yes No

Do you have previous caregiving experience? (required)

Yes No

If yes, How many years?

(Numeric Answer Only)

Have you held 3 or more jobs in the past 5 years? (required)

Yes No

Do you have a High School Diplom or equivalent? (required)

Yes No

Employer: (required)

Start Date: (required)

End Date: (required)

Ending Pay: (required)

(Numeric Answer Only)

Job Title: (required)

Reason(s) for Leaving: (required)

May we contact this employer? (required)

Yes No

Employer: (required)

Start Date: (required)

End Date: (required)

Ending Pay: (required)

(Numeric Answer Only)

Job Title: (required)

Reason(s) for Leaving: (required)

May we contact this employer? (required)

Yes No

Relationship: (required)

Phone Number: (required)

Number of Years Known: (required)

(Numeric Answer Only)

Relationship: (required)

Phone Number: (required)

Number of Years Known: (required)

(Numeric Answer Only)

Can you work with dogs (required)

Yes No

Can you work with cats (required)

Yes No

Can you work with a smoker (required)

Yes No

Can you preform Hoyer Lift (required)

Yes No

Are you willing to drive to Santa Teresa for assignments (required)

Yes No

Wednesday: (required)

Thursday: (required)

Saturday: (required)

Comfort Keepers completes a criminal history check for every applicant. The check will occur at the time of application and annually thereafter. (required)

Yes No

I am an applicant or employee of Comfort Keepers, and herby state that I agree to a criminal background check by Comfort Keepers. (required)

Name: (Electronic Signature) (required)

I have been notified that a computerized criminal history (CCH) verification check will be performed by accessing the applicable Secure Website and will be based on name and date of birth information I supply. (required)

Yes No

Named based criminal history checks are not always exact. I understand that only fingerprint record searches represent true identification to criminal history. If the name search provides a criminal report that I know could not be mine, then I understand I can submit to have a fingerprint search performed to clear any misidentification based on the name search. (required)

Yes No

If I choose to be fingerprinted, I understand that I will be required to submit a full and complete set of my fingerprints for analysis through the appriopriate state agency. I have been made aware that in order to complete this process I must have the correct fingerprinting form from Comfort Keepers. I must submit a complete set of my fingerprints, and pay a fee to the fingerprinting services company (required). (required)

Yes No

Once this process is completed and Comfort Keepers receives the data, the information on my fingerprint criminal history record may be discussed with me. Comfort Keepers is not allowed to discuss any information obtained from the background check process with anyone other than the said individual. (required)

Yes No

Name: (Electronic Signature) (required)

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

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

NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report and/or an investigative report which includes information as to your character, general reputation, personal characteristics and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.” (required)

Yes No

Name: (Electronic Signature) (required)

Date of Signature: (required)

Race/National Origin-Select below that corresponds to the category that best identifies your race/ethnicity

Race/National Origin-Select below that corresponds to the category that best identifies your race/ethnicity- Continued

Comfort Keepers is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other legally protected class. As required by law, we must record certain information to be made a part of our Affirmative Action Program. Applicants are invited to participate in the Affirmative Action Program by reporting their status as minority, disabled veteran or other veteran status, or other disabled. In extending this invitation you are advised that: 1) you are under no obligation to respond, but may do so in the future if you choose; 2) responses will remain confidential within the Human Resources Department; and 3) responses will be used only for the necessary information to include in our Affirmative Action Program.

Date of Application:

Postion Applying for:

Our Company is a federal contractor subject to various federal laws, regulations, and Executive Orders, which require that federal contractors take affirmative action to employ and to advance in employment qualified individuals without discrimination based on a covered veteran status. To fulfill statistical reporting and affirmative action monitoring requirements, we invite you to voluntarily identify your veteran status by answering the questions below. Submission of this information is voluntary and no adverse consequences will result from either the disclosure or refusal to provide this information. The information that you submit will also be kept confidential as required under applicable federal and/or state laws. Should you decide not to self-identify at this time, you may do so at any time in the future.

Comfort Keepers Las Cruces 561 Application Form

Personal Information

Section 1 - General Information

Section 2 - Employment Information

Section 3 - Educational Background

Section 4 - Most Recent Employer

Section 5 - Second Most Recent Employer

Section 6 - Professional Reference 1 ( Cannot Be Family)

Section 7 - Professional Reference 2 (Cannot be Family)

Section 8 - Assignment Elements

Section 9 - Availability (Times available for work)

Section 10 - Criminal History Disclosure

Section 11 - DPS Computerized Criminal History(CCH)Verification

Section 12 - Applicants Certification and Agreement

Section 14 - Affirmative Action Survey

Section 16 - VETS-100 Employment Survey