Please fill out all of the sections below:

Applicant Information

Applicant Name:

Address:

City, State and Zip Code:

Telephone Number:

Email Address:

Employment Position

Position(s) applying for: CNA / Caregiver circle one (a license is not required)

How did you hear about this position?

What days are you available for work?
SuMoTuWeThFrSa

If needed, are you available to work overtime?

On what date can you start working if you are hired?

Do you have reliable transportation to and from work and can show proof of current insurance?

Salary desired:

Personal Information

Have you ever applied to or worked for Comforting Assistance before?
YesNo

If yes, when?

Do you have any friends, relatives, or acquaintances working for Comforting Assistance
YesNo

If yes, state name & relationship:

Are you 18 years of age or older?
YesNo

Are you a U.S. citizen or approved to work in the United States?
YesNo

What document can you provide as proof of citizenship or legal status?

Do you have any condition which would require job accommodations?
YesNo

Do you have any condition which would require job accommodations?

Job Skills/Qualifications (Must Have A Current CPR card to begin working)

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Comforting Assistance complies with the ADA and considers reasonable accommodation measures
that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a
hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical
professional.

Education and Training

High School

College/University

Vocational School/Specialized Training

Military:

Are you a member of the Armed Services?
[tex* armed-member]

What branch of the military did you enlist?


What was your military rank when discharged?


How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

References

Please provide 3 personal and professional reference(s) below:

Additional Information:

This position, depending on the clients, may require assistance with meals and housekeeping. Are you able
and willing to assist in these activities?

This position may or may not require a basic skills test. Are you able and willing to participate in a basic
skills quiz and/or test?

AT-WILL EMPLOYMENT

The relationship between you and the Comforting Assistance is referred to as "employment at will." This
means that your employment can be terminated at any time for any reason, with or without cause, with or
without notice, by you or the Comforting Assistance. No representative of Comforting Assistance has
authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You
understand that your employment is "at will," and that you acknowledge that no oral or written statements or
representations regarding your employment can alter your at-will employment status, except for a written
statement signed by you and a representative of this company.