Comfort Hands Healthcare

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Application Date

Position Desired

Last Name

First Name

Middle Initial

	Street	City	State	Zip
Current Address
Previous Address

Daytime #

Evening #

Email

Social Security # Enter numbers without dashes.

Are you at least 18 years of age? YesNo

Driver License #

State of Issue

Car Insurance Carrier

Fax #

Are you related to anyone presently at CHHC? YesNo

Name and Department

How did you hear about CHHC?

Ad

Agency

Employee Referral Name

Other

Have you ever been charged with, or convicted of any criminal offenses an adult in a civilian or military court? YesNo

Offense Date

Nature of Offense

Disposition

Authority of Court

City/State/Zip

Country

Note: Criminal charge(s) or conviction(s) will not automatically disqualify you from consideration for employment at CHHC.

If hired, can you present evidence of your legal right to live and work in this country (on a permanent basis)? YesNo

Please Explain

Do you have a high school diploma/GED? YesNo

List education (begin with post high school and include college or ay technical training):

	Name of School	Location	MM/YY Complete	Degree	Major

List computer or other skill areas you have expertise in or special licenses or certifications (include # & expiration date):

List your last four employers starting with your most recent, or go back 10 years if applicable; include military service.

May we contact your current employer to verify employment? YesNo

Date

Name and Address of Employer

Title & Responsibilities

Pay Start

Pay End

Reason For Leaving

Mgr/Supv

Phone:

Name (3) business contacts in your field that have knowledge of your technical competence whom we have permission to contact as a reference, preferably former supervisors and managers with whom you have worked.

Reference #1

Name

Address

Business Name

Business Phone

Title

Reference #2

Name

Address

Business Name

Business Phone

Title

Reference #3

Name

Address

Business Name

Business Phone

Title

By submitting, I certify that the answers given in this application for employment are true and correct to the nest of my knowledge. I authorize investigations of all statements contained in the application including a DMV check and/or background check performed by a third party agency. I understand that a drug screening and a physical exam may be required for employment, failure to pass these exams may result in my discharge if hired. I also understand any false or misleading information given in this application or during a pre-employment interview, including a failure to disclose requested information, may result in my discharge if hired.

I understand that any employment relationship with this employer is "at-will," which means that the employee may resign at any time and the employer may discharge the employees at any time, with or without cuase. I also understand that this at-will employment relationship may not be changed by any written document or by any behavior, unless the change is specifically acknowledged in writing by the Administrator.

Comfort Hands Healthcare, Inc. is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRIMINATE AGAINST RACE, RELIGION, AGE, GENDER, SEXUAL ORIENTATION, DISABILITY (MENTAL OR PHYSICAL), COMMUNICABLE DISEASE, OR PLACE OF NATIONAL ORIGIN.

i have read and understood the above prior to submitting this application.

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Copyright � 2012 Comfort Hands Healthcare