Online Application Form For Care And Comfort Providers - Page 2 0f 2
Do you have have any transportation to work? __________________________________________________________
Do you drive? ____________ Driver's License Number? ______________ Expiration of Driver's License______________
How many miles are you willing to travel? ____________ What foreign language do you speak? __________________
Former Employers:
Name of Employer: ____________________________ Address: _____________________________________________
Date, Month, and Year: _____________________________________________________________________________
Salary: ______________________________________ Position: _____________________________________________
Name of Employer: ____________________________ Address: _____________________________________________
Date, Month, and Year: _____________________________________________________________________________
Salary: ______________________________________ Position: _____________________________________________
Have you ever worked in a Home Health Agency before? ______________________ Date: ______________________
If Yes, please tell us the name of the Home Health Agency: _______________________________________________
Other information: _________________________________________________________________________________
Personal References: Name one person not related to you, whom you have known for at least a year.
Name: _________________________________________________ Phone Number: _____________________________
In case of emergency, notify:
Name: _________________________________________________ Phone Number: _____________________________
My signature will authorize an investigation of all statements contained in this application. I understand and agree my false
statement or misrepresentation in this application will result in refusal to hire, or immediate dismissal of my services, without any
liability for wages of salary except earned monies due to such termination.
Applicant's Signature: _____________________________________________ Date: ___________________________
CCP Representative: ______________________________________________ Date: ___________________________
Do you have have any transportation to work? __________________________________________________________
Do you drive? ____________ Driver's License Number? ______________ Expiration of Driver's License______________
How many miles are you willing to travel? ____________ What foreign language do you speak? __________________
Former Employers:
Name of Employer: ____________________________ Address: _____________________________________________
Date, Month, and Year: _____________________________________________________________________________
Salary: ______________________________________ Position: _____________________________________________
Name of Employer: ____________________________ Address: _____________________________________________
Date, Month, and Year: _____________________________________________________________________________
Salary: ______________________________________ Position: _____________________________________________
Have you ever worked in a Home Health Agency before? ______________________ Date: ______________________
If Yes, please tell us the name of the Home Health Agency: _______________________________________________
Other information: _________________________________________________________________________________
Personal References: Name one person not related to you, whom you have known for at least a year.
Name: _________________________________________________ Phone Number: _____________________________
In case of emergency, notify:
Name: _________________________________________________ Phone Number: _____________________________
My signature will authorize an investigation of all statements contained in this application. I understand and agree my false
statement or misrepresentation in this application will result in refusal to hire, or immediate dismissal of my services, without any
liability for wages of salary except earned monies due to such termination.
Applicant's Signature: _____________________________________________ Date: ___________________________
CCP Representative: ______________________________________________ Date: ___________________________
THE CONFIDENT CHOICE
29359 West Dakota Dr., Santa Clarita, California 91354 USA
1-818-274-2132
1-661-775-3789
29359 West Dakota Dr., Santa Clarita, California 91354 USA
1-818-274-2132
1-661-775-3789
Care and Comfort Providers