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(954) 667-5500
comfortingcarehhc@outlook.com
2455 Hollywood Blvd, Suite# 210, Hollywood, Florida 33020
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Home
About
Services
Homemaker Services
Companion Care
Respite Care
Private Duty Care
Post-Hospital Care
Transportation & Errands
FAQs
Blog
Service Areas
Careers
Contact
Schedule Consultation
Request Our Services
Application Form
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Applicant Information
Full Legal Name
Preferred Name (if different)
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Resumes, IDs and Any Other Supporting Document
Date of Application
MM slash DD slash YYYY
Phone Number
Alternate Phone
Email Address
Current Address
Street Address
City
State
ZIP
Are you 18 years of age or older?
Yes
No
Are you legally authorized to work in the United States?
Yes
No
If hired, can you provide proof of work authorization?
Yes
No
Position Sought
Position Applying For (check all that apply)
Homemaker
Companion
Personal Care Aide
Live-In Caregiver
Other
Other
Employment Type
Full-Time
Part-Time
PRN
Live-In
Overnight
Availability (days/hours)
Desired Start Date
MM slash DD slash YYYY
Willing to work on weekends/holidays?
Yes
No
Professional Credentials & Eligibility
Do you have a valid Driver’s License?
Yes
No
State
Reliable Transportation?
Yes
No
Auto Insurance (if driving for work)
Yes
No
CPR Certification
Yes
No
Expiration Date
MM slash DD slash YYYY
First Aid Certification
Yes
No
Expiration Date
MM slash DD slash YYYY
Professional License/Certification (if applicable)
Type
Number
Issuing State
Expiration Date
MM slash DD slash YYYY
Have you ever been excluded from Medicare/Medicaid programs?
Yes
No
Caregiving Skills & Experience
Years of caregiving experience
<1
1–3
3–5
5+
Settings Worked (check all that apply)
Private Home
Assisted Living
Skilled Nursing Facility
Hospital
Hospice
Please indicate experience with the following (check all that apply)
Personal Care (bathing, grooming, toileting)
Mobility & Transfers
Meal Preparation
Medication Reminders
Dementia/Alzheimer’s Care
Parkinson’s Care
Stroke Recovery
Incontinence Care
Light Housekeeping
Transportation/Errands
Companionship
Skills/Training
Employment History
Most Recent Employer
Employer Name
Address
Phone
Supervisor Name/Title
Job Title
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
Previous Employer
Employer Name
Address
Phone
Supervisor Name/Title
Job Title
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for Leaving
References (Professional Only)
Reference 1
Name
Relationship
Phone
Email
Reference 2
Name
Relationship
Phone
Email
Background & Compliance
Have you ever been convicted of a crime (excluding sealed/expunged records)?
Yes
No
If yes, please explain (a conviction does not automatically disqualify you)
Are you willing to undergo a background check and drug screening if required?
Yes
No
Are you able to perform the essential functions of the job with or without reasonable accommodation?
Yes
No
Emergency Contact
Name
Relationship
Phone Number
Applicant Acknowledgment & Authorization
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in disqualification from employment consideration or termination if hired. I authorize Comfort Care to verify information, contact references, and conduct background checks as permitted by law.
I understand that employment, if offered, is at-will and may be terminated by either party at any time, with or without cause or notice, in accordance with applicable law.
Applicant Signature
Date
MM slash DD slash YYYY
Office Use Only
Application Received By
Date
MM slash DD slash YYYY
Interview Date(s)
MM slash DD slash YYYY
Notes
Status
Pending
Hired
Not Selected
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