Allied Home Healthcare Network

Member of Allied Home
Healthcare Network

Comfort Plus Hospice

612 W. Jackson St..
Morton, IL 61550
Phone: (309) 620-9821
Fax: (309) 620-9822

Page 1 of 4

Comfort Plus Hospice Employment Application
  1. Online Application Start
  2. First name(*)
    Enter your first name
  3. Middle name
    Enter middle name
  4. Last name(*)
    Enter last name
  5. Phone number
    i.e. 123-456-7890(*)
    Enter phone number (i.e. 123-456-7890)
  6. Email address(*)
    Enter email address
  7. Street address(*)
    Enter street address
  8. City(*)
    Enter city
  9. State(*)
    Enter state
  10. Zip code(*)
    Enter zip code
  11. How'd you find out about this job(*)
    Select answer
  12. Briefly explain other(*)
    Briefly explain other
  13. Are you at least 18 years of age(*)
    Select answer
  14. Can you furnish work permit(*)
    Enter yes or no
  15. Applied with us before(*)
    Select answer
  16. Date of that appliaction
    Choose from calendar or type
    date manually like MM/DD/YYYYY

    Enter date of application
  17. Have you ever worked for
    this organization before(*)
    Select answer
  18. Employment start date(*)
    / / Enter employment start date
  19. Employment end date(*)
    / / Enter employment end date
  20. Are you currently employed(*)
    Select answer
  21. May we contact your employer
    That info you'll list later(*)
    Enter yes or no
  22. Briefly explain why you
    do not wish us to
    contact present employer(*)
    Briefly explain 'no' answer
  23. Are you legally eligible for
    employment in the U.S.(*)
    Select answer
  24. Are you a veteran(*)
    Select answer
  25. Beginning service date(*)
    / / Enter service begin date
  26. Ending service date(*)
    / / Enter service end date
  27. Discharge type(*)
    Enter discharge type
  28. Any home care experience(*)
    Select answer
  29. Briefly explain experience(*)
    Explain P.O.S. experience
  30. Type of employment seeking(*)
    Select answer
  31. Position applying for(*)
    Select position apply for
  32. Briefly explain the hours
    you prefer to work(*)
    Briefly explain the hours and shift(s)
    you prefer to work
  33. Briefly explain times you
    are not available to work(*)
    Briefly explain times you're
    not available to work
  34. Can you work weekends(*)
    Select answer
  35. Can you work holidays(*)
    Select answer
  36. Select the date on the calendar
    that you would be able to start(*)

    Select availability date on the calendar
  1. Information and Education
  2. Have friends or relatives that
    work or have worked for
    Comfort Plus Hospice(*)
    Select answer
  3. List those friends
    and/or relatives(*)
    List any friends or relatives
    from your answer above
  4. Are you able to perform normal
    job tasks without accommodation(*)
    Select answer
  5. Describe the types of tasks you need
    accommodation for and the type
    of accommodations needed(*)
    Describe the types of tasks you need
    accommodation to perform and the type
    of accommodations you will need
  6. Convicted of a felony within
    the last 7 years?(*)
    Select answer
  7. Briefly explain
    i.e. nature of felony, disposition,
    dates & places
    (*)
    Briefly explain felony conviction
  8. Emergency contact person
  9. Name(*)
    Emergency contact name
  10. Relationship to you(*)
    Their relationship to you
  11. Phone (cell preferred)
    i.e. 123-456-7890(*)
    Emergency contact phone number
  12. Street address(*)
    Emergency contact street address
  13. City(*)
    City of emergency contact
  14. State(*)
    State of emergency contact
  15. Zip code(*)
    Zip code of emergency contact
  16. Education
  17. Elementary
    Select answer
  18. Name of elementary school
    Invalid Input
  19. Location of elementary school
    Invalid Input
  20. High School
    Select answer
  21. Name of high school
    Invalid Input
  22. Location of high school
    Invalid Input
  23. If in high school now, are you
    enrolled in a co-op program
    Invalid Input
  24. List Co-op program
    and school(*)
    List Co-op program and associated school
  25. College level
    Select answer
  26. Name of college
    Invalid Input
  27. Location of college
    Invalid Input
  28. Degree and Major
    Invalid Input
  29. Minor
    Invalid Input
  30. Personal reference - one
  31. Name
    Enter personal reference name
  32. Address
    Enter personal reference address
  33. Phone
    i.e. 123-456-7890
    Enter phone number (xxx-xxx-xxxx)
  34. Personal reference - two
  35. Name
    Enter personal reference name
  36. Address
    Enter personal reference address
  37. Phone
    i.e. 123-456-7890
    Enter phone number (xxx-xxx-xxxx)
  38. Personal reference - three
  39. Name
    Enter personal reference name
  40. Address
    Enter personal reference address
  41. Phone
    i.e. 123-456-7890
    Enter phone number (xxx-xxx-xxxx)
  1. Work History
    most recent first
  2. Work history one
  3. Company
    Invalid Input
  4. Company phone
    i.e. 123-456-7890
    Phone number format: 123-456-7890
  5. Address
    Invalid Input
  6. City
    Invalid Input
  7. State
    Invalid Input
  8. Zip code
    Number and dashes are acceptable input
  9. Employment started
    --Invalid Input
  10. Employment ended
    --Invalid Input
  11. Starting salary
    Invalid Input
  12. Ending salary
    Invalid Input
  13. Job title
    Invalid Input
  14. Supervisor name and title
    Invalid Input
  15. Briefly describe duties
    Invalid Input
  16. Specific reason for leaving
    Invalid Input
  17. Work history two
  18. Company
    Invalid Input
  19. Company phone
    i.e. 123-456-7890
    Phone number format: 123-456-7890
  20. Address
    Invalid Input
  21. City
    Invalid Input
  22. State
    Invalid Input
  23. Zip code
    Number and dashes are acceptable input
  24. Employment started
    --Invalid Input
  25. Employment ended
    --Invalid Input
  26. Starting salary
    Invalid Input
  27. Ending salary
    Invalid Input
  28. Job title
    Invalid Input
  29. Supervisor name and title
    Invalid Input
  30. Briefly describe duties
    Invalid Input
  31. Specific reason for leaving
    Invalid Input
  1. Work History & App. Finish
  2. Work history three
  3. Company
    Invalid Input
  4. Company phone
    i.e. 123-456-7890
    Phone number format: 123-456-7890
  5. Address
    Invalid Input
  6. City
    Invalid Input
  7. State
    Invalid Input
  8. Zip code
    Number and dashes are acceptable input
  9. Employment started
    --Invalid Input
  10. Employment ended
    --Invalid Input
  11. Starting salary
    Invalid Input
  12. Ending salary
    Invalid Input
  13. Job title
    Invalid Input
  14. Supervisor name and title
    Invalid Input
  15. Briefly describe duties
    Invalid Input
  16. Specific reason for leaving
    Invalid Input
  17. Work history four
  18. Company
    Invalid Input
  19. Company phone
    i.e. 123-456-7890
    Phone number format: 123-456-7890
  20. Address
    Invalid Input
  21. City
    Invalid Input
  22. State
    Invalid Input
  23. Zip code
    Number and dashes are acceptable input
  24. Employment started
    --Invalid Input
  25. Employment ended
    --Invalid Input
  26. Starting salary
    Invalid Input
  27. Ending salary
    Invalid Input
  28. Job title
    Invalid Input
  29. Supervisor name and title
    Invalid Input
  30. Briefly describe duties
    Invalid Input
  31. Specific reason for leaving
    Invalid Input
  32. -----------------------------------------
  33. May we contact
    previously employers(*)
    Select answer
  34. List employers you do not
    wish us to contact and why
    Invalid Input
  35. For any appliation information
    you provided, have you used a
    differen name in the past(*)
    Select answer
  36. Provide name or names you
    used and the organization(*)
    Provide the name or names
    used and the organization
  37. Briefly list any additional skills
    or training you may have
    Invalid Input
  38. You must agree to the Applicant's Statement
    to submit your application.