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Application For Employment

  Date:
INSTRUCTION: Please read carefully. Every item on this form must be answered to the best of your ability.
Your qualification will be carefully reviewed and you will be given thorough consideration for any suitable opening. Upon employment, this application will become part of your personnel record with Comfort Ease Home Care.

Keep this in mind as you complete it. Note: Ohio is an “At-will state” meaning that the employer or employee can terminate employment at any time and no reason for termination is needed by either party. You are not required to supply any information that is prohibited by Federal, State or local law.

Comfort Ease Home Care does not discriminate on the basis of race, color, religion, sex, national origin, citizenship, age, marital status or disability . You may request assistance in completing this application.

Last Name:
First Name:
MI:
Social Security Number:
Phone Number :
Address:
City: State: Zip:
 
Mailing Address: (if different from above)
Address:
City: State: Zip:
Emergency Contact:
Relation: Phone Number:
Have you ever worked for or applied for work with Comfort Ease Home Care previously?

Have you had any experience related to caregiving?

Other:
Are you currently certified as a CNA? (certification is not required for employment with our company.)
Do you have other certifications or licenses?
If so, please list them in the space provided below.
Type of employment sought:
When are you available for work?
Indicate hours you are available to work on the following days:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
To To To To To To To
Are you available for live-ins?
If so, what days?
How did you hear about Comfort Ease Home Care?

Have you ever been convicted of a crime other than a minor traffic violation?
If yes, please explain
 
EMPLOYMENT HISTORY: please list ALL PLACES OF EMPLOYMENT in chronological order , beginning with your current or most recent employer. Please request another reference page if need.
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
Job Title
Employer
Address:
City, State, Zip
Phone Number
Supervisor
Reason for Leaving
Dates Employed From
To
 
 

PERSONAL REFERENCES

 
01. Name Phone Number
02. Name Phone Number
03. Name Phone Number
 
I certify that all information is true and correct to the best of my knowledge and give Comfort Ease Home Care permission to check all previous places of employment and references listed above.
 
Signature Date

Phone Number: 216.245.6139

Fax Number: 216.245.6382