COMCARE EMPLOYMENT APPLICATION

Step 1 of 7

14%

All Applicants Must: • Be 18 Years of Age • Have a Valid Tennessee Driver’s License with a clear driving record (must have held the license for 2 years not counting your learners permit) • Have a Social Security Card • Have Proof of Vehicle Liability Insurance • Be Able to Pass Employee Drug Testing • Be Able to Pass Employee TB Testing • Be Able to Pass FBI/TBI Fingerprinting • Be Able to Pass All Other Required Background Checks

By checking the box I understand and agree to that I meet the above criteria for employment. I also understand that unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature. *(Required)

Yes, I agree

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, genetic information or the presence of a non-job-related medical condition or handicap.

Date of Application(Required)

MM slash DD slash YYYY

Position(s) Applied For(Required)

Referral Source:(Required)

Walk-In

Friend/Relative

Other

IF FRIEND/RELATIVE, PROVIDE NAME OF REFERRAL SOURCE IF COMCARE EMPLOYEE:

Personal Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

HAVE YOU RESIDED AT THE ABOVE ADDRESS FOR THE PAST FIVE YEARS?(Required)

Yes

LIST ANY PREVIOUS ADDRESSES YOU HAVE HAD FOR THE PAST FIVE YEARS.(Required)

Home Telephone(Required)

If not home number - relationship to you:(Required)

Cell Phone(Required)

Cell Phone or Second Contact Number

Email(Required)

HAVE YOU FILED AN APPLICATION HERE BEFORE?(Required)

Yes

IF YES, GIVE DATE OF PREVIOUS APPLICATION:

MM slash DD slash YYYY

ARE YOU AVAILABLE TO WORK:(Required)

Full-Time

Part-Time

CHECK ALL SHIFTS FOR WHICH YOU ARE INTERESTED:(Required)

FLEXIBLE JOB COACH (SHIFT AND DAY VARIES)

DAY SHIFTS (MONDAY-FRIDAY)

2ND SHIFT (SUNDAY-THURSDAY)

2ND SHIFT (SUNDAY-THURSDAY) PLUS SLEEPOVER

2ND SHIFT (MONDAY-FRIDAY)

2ND SHIFT (MONDAY-FRIDAY) PLUS SLEEPOVER

AWAKE SHIFT (MONDAY-THURSDAY)

AWAKE SHIFT (FRIDAY-SATURDAY-SUNDAY)

WEEKEND SHIFT (FRIDAY 2ND SHIFT, ALL DAY SATURDAY, 1ST SHIFT SUNDAY)

WEEKEND SHIFT (FRIDAY 2ND SHIFT PLUS SLEEPOVER, ALL DAY SATURDAY PLUS SLEEPOVER, 1ST SHIFT SUNDAY)

WEEKEND SHIFT (ALL DAY SATURDAY AND SUNDAY)

WEEKEND SHIFT (ALL DAY SATURDAY AND SUNDAY PLUS SLEEPOVERS)

HAVE YOU EVER BEEN CHARGED, CONVICTED, OR PLED GUILTY TO, ANY TYPE OF CRIME OTHER THAN THAT OF A MINOR TRAFFIC VIOLATION?(Required)

Yes

HAVE YOU HAD A VALID TENNESSEE DRIVER'S LICENSE FOR AT LEAST TWO YEARS?(Required)

Yes

DO YOU HAVE PROOF OF VEHICLE LIABILITY INSURANCE?(Required)

Yes

HAVE YOU HAD ANY VEHICLE ACCIDENTS OR MOVING VIOLATIONS (INCLUDING SPEEDING TICKETS) WITHIN THE PAST THREE YEARS?(Required)

Yes

IF YES, PLEASE DESCRIBE:

HAS YOUR DRIVER'S LICENSE BEEN RESTRICTED, SUSPENDED OR REVOKED WITHIN THE PAST THREE YEARS?(Required)

Yes

Education

School Name(Required)

YEARS COMPLETED:(Required)

Associate's Degree

Bachelor's Degree

Graduate Degree

Other

DIPLOMA OR DEGREE(Required)

Yes

Other

STATE ANY ADDITIONAL INFORMATION YOU FEEL MAY BE HELPFUL TO US IN CONSIDERING YOUR APPLICATION.(Required)

REFERENCES

Give names and telephone numbers of five (5) references who ARE NOT RELATED to you and ARE NOT PREVIOUS EMPLOYERS. List at least two (2) references that you have known for at least five (5) years. List the number of years each person has known you.

REFERENCE #1 List Name of Personal Reference, Years Known, Phone Number, Alternate Phone Number(Required)

REFERENCE #2 List Name of Personal Reference, Years Known, Phone Number, Alternate Phone Number(Required)

REFERENCE #3 List Name of Personal Reference, Years Known, Phone Number, Alternate Phone Number(Required)

REFERENCE #4 List Name of Personal Reference, Years Known, Phone Number, Alternate Phone Number(Required)

REFERENCE #5 List Name of Personal Reference, Years Known, Phone Number, Alternate Phone Number(Required)

EMPLOYEE EXPERIENCE

Please give a history of your employment experience for at least the past 5 years. Start with your present or last job. Include all work history, military service assignments and volunteer activities. Please provide the following information: • Employer Name • Street Address, City, State, & Zip Code • Phone Number • Job Title • Name of Supervisor • Work Performed • Dates Employed • Hourly Rate / Salary (Starting - Final) • Reason for Leaving

EMPLOYER #1 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #2 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #3 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #4 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #5 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #6 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #7 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #8 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #9 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

EMPLOYER #10 Please provide the following information: Employer Name, Street Address, City, State, & Zip Code, Phone Number, Job Title, Name of Supervisor, Work Performed, Dates Employed, Hourly Rate / Salary (Starting - Final), and Reason for Leaving.(Required)

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company. By signing or typing my name on the following line I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information. Type name:(Required)

Name

This field is for validation purposes and should be left unchanged.