Comfort Keepers of Southern Maine

Comfort Keepers of Southern Maine Application Form

Application Form

An Equal Opportunity Employer Qualified applicants are considered for all positions without regard to race, color, gender, sexual orientation, national origin, age, marital status, non-related medical condition or disability, or any other status protected by law. If you are on Internet Explorer, you may have issues completing and/or submitting the application. If you do, please call us at 207-885-9600

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Section 1 - General Information

How long have you been at your current address? (required)

How did you hear about us? (required)

Are you legally eligible to work in the US? (required)

Yes No

Do you have a High School Diploma or GED? (required)

Yes No

Do/have you held a valid driver's license for more than 3 years? (required)

Yes No

Is your auto insurance current? (required)

Yes No

If no to either of the above 2 questions, please explain

Summarize any training, skills, licenses, certificates, and/or personal experience and interests that may qualify you for this position:

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Section 2 - Essential Functions of the position

Are you physically able to push a client in a wheelchair or reposition a client?

Yes No

Are you able to pull, such as pulling an occupied wheelchair or repositioning a client?

Yes No

Are you able to safely be in a squatting position to assist a client with mobility limitations?

Yes No

Are you able to safely be in a kneeling position to help a client with mobility limitations?

Yes No

Are you able to lift 25 pounds regularly?

Yes No

Section 3 - Availability

Are you willing to work more than 20 hours per week? (required)

Yes No

How many hours? (required)

When are you available to start? (required)

What specific hours can you work on Monday? (if any) (required)

What specific hours can you work on Tuesday? (if any) (required)

What specific hours can you work on Wednesday? (if any) (required)

What specific hours can you work on Thursday? (if any) (required)

What specific hours can you work on Friday? (if any) (required)

What specific hours can you work on Saturday? (if any) (required)

What specific hours can you work on Sunday? (if any) (required)

Are you available to do awake overnights? (required)

Yes No

Are you able to commit to a regular weekend schedule?

Section 4 - Applicant Survey-Would you be comfortable with:

Assisting a female with bathing and toileting needs? (required)

Yes No

Assisting a male with bathing and toileting needs? (required)

Yes No

Caring for someone with Alzheimer's/Dementia? (required)

Yes No

Caring for someone in Hospice? (required)

Yes No

Caring for someone in a hospital or assisted living program? (required)

Yes No

Caring for someone who has pets?

People who smoke?

Yes No

Transporting clients in your own car?

Yes No

Working with other family members who visit or live with the client?

Yes No

Do you have environmental allergies such as cats and/or dogs? (required)

Yes No

Do you consider yourself a good cook? (required)

Yes No

Do you enjoy light housekeeping (required)

Yes No

Comments:

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Section 5 - Employment History

Employer (current or most recent) (required)

Address

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Dates worked for:

Describe Your Responsibilities: (required)

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Supervisor's Name

May we contact this employer for a reference? (required)

Yes No

Phone #:

Section 6 - Pevious employment

Employer: (required)

Address: (required)

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Dates worked for:

Describe Your Responsibilities:

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Supervisor's Name

May we contact this employer for a reference?

Phone #: (required)

Section 7 - Previous Employment

Employer

Address: (required)

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Dates worked for:

Describe Your Responsibilities:

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Supervisor's Name

May we contact this employer for a reference?

Yes No

Phone #:

Section 8 - Personal References (NO FAMILY MEMBERS)

First and Last name (required)

Phone Number: (required)

Relationship: (required)

Years Known: (required)

Email address:

Section 9 - Personal References (NO FAMILY MEMBERS)

First and Last name

Phone Number:

Relationship:

Years Known:

Email address:

Section 10 - Personal Refer (NO FAMILY MEMBERS)

First and Last name

Phone Number:

Relationship:

Years Known:

Email address:

I certify that the facts contained in this application are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or discipline up to and including my dismissal from employment if discovered at a later date. I understand that my application will be reviewed and that I will be contacted by Comfort Keepers regarding the status of my application or to set up an interview. If I am not hired, my application will be kept on file for 60 days. I give the employer and or its agents, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This may include, but not be limited to, criminal history/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. IF YOU ARE HAVING A HARD TIME SUBMITTING THIS APPLICATION, PLEASE CALL THE OFFICE AT 207-885-9600.

Signature