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Position Applied For...
CaregiverHome Health Aide (HHA)Certified Nurse Assistant (CNA)State Tested Nurse Assistant (STNA)Direct Support Professionals (DSP)

Date of Application

First Name

Last Name

Email Address

Phone Number

Address

City

State

Postal Code

Date of Birth

Driver's License Number

Social Security Number

Have you filed an application with Comfort Ease Home Care, LLC before?
YesNo

If yes, please provide the date of previous application

Have you been fingerprinted within the last 12 months?
YesNo

Will you travel if job requires it?
YesNo

PREVIOUS WORK HISTORY

If you have a resume, please upload here

EMPLOYER #1

Employer #1

Employer Phone Number

Employer Address

Employer's Job Title

Supervisor's Name and Title

Reason for Leaving

May we contact previous employer #1 for reference?
YesNoLater

Date Employed From

Date Employed To

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Summarize the nature of the work performed

EMPLOYER #2 (if applicable)

Employer #2

Employer Phone Number

Employer Address

Employer's Job Title

Supervisor's Name and Title

Reason for Leaving

May we contact previous employer #2 for reference?
YesNoLater

Date Employed From

Date Employed To

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Summarize the nature of the work performed

Authorization to Release Information
I,
authorize my employers, supervisors, and managers (both current and former), educational institutions, and any other individuals or organizations contacted regarding my background to provide Comfort Ease Home Care, LLC with any and all information, including opinions, concerning my employment history, professional abilities, accomplishments, and personal traits or characteristics for the purpose of evaluating my qualifications and potential success with Comfort Ease Home Care, LLC.

I authorize Comfort Ease Home Care, LLC to obtain my criminal history to the extent permitted under Ohio state law. I further authorize Comfort Ease Home Care, LLC to obtain information about me from any third parties it deems appropriate to contact.

I release and agree to hold harmless all persons or entities from any liability for damages that may arise from furnishing information to Comfort Ease Home Care, LLC.

I also release Comfort Ease Home Care, LLC from any liability related to gathering, reviewing, or relying upon the information provided.

I authorize Comfort Ease Home Care, LLC to obtain such information confidentially. I understand that the company may maintain the confidentiality of this information and may not be required to disclose it to me or to any other person upon my request.

I understand and agree that any misrepresentation or false information provided by me on this application may be sufficient cause for rejection of my application or termination of employment if I have already been hired.

Comfort Ease Home Care, LLC is an Equal Opportunity Employer. The company does not discriminate in employment, and no question on this application is used to limit or exclude any applicant from consideration for employment on any basis prohibited by local, state, or federal law.

This application will remain active for 60 days. If I have not been contacted within that time and wish to continue being considered for employment, I understand that I must complete a new application.

I understand that, just as I am free to resign from employment at any time, the employer reserves the right to terminate my employment at any time, with or without notice. I further understand that no representative of the company has the authority to make any assurances to the contrary.

I understand that it is the company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for reasonable accommodation, as required by the Americans with Disabilities Act (ADA).

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