Franchise 3031 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.
Office Location
Select Office Location
-- Select Office --
Collingwood
Midland
Owen Sound
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
Postion for Personal Support Worker
(required)
Are you a Certified Personal Support Worker?
(required)
Yes
No
Do you have your own reliable transportation in order travel to and from work as well as between clients?
(required)
Yes
No
Drivers License Expiration Date
Expiration Date
Auto License Expiration Date
Expiration Date
Have you ever been convicted of,or plead quilty or no contest to,a misdemeanor or felony?
(required)
Yes
No
Best time to call you:
(required)
Have you previously worked for Comfort Keepers?
Yes
No
Are you legally eligible to work in Canada?
(required)
Yes
No
Where did you hear about Comfort Keepers?
(required)
-- Select an Option --
Web
Indeed
Word of Mouth
Tracks/Career Solutions
Section 2 -
Availability
What week days are you available?
(required)
What week ends are you available?
(required)
What times are you available?
(required)
Are you able to do mornings, afternoon and overnights
(required)
Show Plain Text
Are there any day/times that you are absolutely not available?
(required)
Are you available to be called in an emergency?
(required)
Yes
No
Section 3 -
Employment Information
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodations?
Yes
No
Please describe the functions that cannot be performed:
Section 4 -
Education
High School
(required)
Yes
No
Name and City
(required)
How many years attended?
(Numeric Answer Only)
Graduated
(required)
Yes
No
Additional Education (vocational, under-graduate, etc)
(required)
Yes
No
If yes, please list the name of the school and years attended (From/To)
Show Plain Text
Section 5 -
Most Recent Employer
Hourly Wage
Address and Phone Number
City, Province
Start Date
End Date
Position Title
Supervisor name/Title
Reason(s) for Leaving:
Summarize the nature of the work performed and job responsibilities
Show Plain Text
May we contact?
Yes
No
Section 6 -
Second Most Recent Employer
Hourly Wage
Address and Phone Number
Start Date
End Date
City, Province
Position Title
Name of Supervisor
Reason(s) for Leaving:
Summarize the nature of the work performed and job responsibilities
Show Plain Text
May we contact?
Yes
No
Section 8 -
Other Employers and Comments
Comments and other Skills, licenses/certification and qualifications (including explanation of any gaps in employment)
Show Plain Text
Do you have a current (within 1 year) Criminal Record Check?
(required)
Yes
No
What languages do you speak?
Section 9 -
Professional References
Reference 1
(required)
Telephone Number
(required)
(Numeric Answer Only)
Years Known
(required)
(Numeric Answer Only)
Professional Relationship
(required)
Section 10 -
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