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

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

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

 
Select availability date on the calendar
   
Information and Education 
Have friends or relatives that
work or have worked for
Comfort Plus Hospice(*)
 
Select answer
List those friends
and/or relatives(*)
 
List any friends or relatives
from your answer above
Are you able to perform normal
job tasks without accommodation(*)
 
Select answer
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
Convicted of a felony within
the last 7 years?(*)
 
Select answer
Briefly explain
i.e. nature of felony, disposition,
dates & places
(*)
 
Briefly explain felony conviction
Emergency contact person 
Name(*)  
Emergency contact name
Relationship to you(*)  
Their relationship to you
Phone (cell preferred)
i.e. 123-456-7890(*)
 
Emergency contact phone number
Street address(*)  
Emergency contact street address
City(*)  
City of emergency contact
State(*)  
State of emergency contact
Zip code(*)  
Zip code of emergency contact
Education 
Elementary  
Select answer
Name of elementary school  
Invalid Input
Location of elementary school  
Invalid Input
High School  
Select answer
Name of high school  
Invalid Input
Location of high school  
Invalid Input
If in high school now, are you
enrolled in a co-op program
 
Invalid Input
List Co-op program
and school(*)
 
List Co-op program and associated school
College level  
Select answer
Name of college  
Invalid Input
Location of college  
Invalid Input
Degree and Major  
Invalid Input
Minor  
Invalid Input
Personal reference - one  
Name  
Enter personal reference name
Address  
Enter personal reference address
Phone
i.e. 123-456-7890
 
Enter phone number (xxx-xxx-xxxx)
Personal reference - two  
Name  
Enter personal reference name
Address  
Enter personal reference address
Phone
i.e. 123-456-7890
 
Enter phone number (xxx-xxx-xxxx)
Personal reference - three 
Name  
Enter personal reference name
Address  
Enter personal reference address
Phone
i.e. 123-456-7890
 
Enter phone number (xxx-xxx-xxxx)
   
Work History
most recent first 
Work history one  
Company  
Invalid Input
Company phone
i.e. 123-456-7890
 
Phone number format: 123-456-7890
Address  
Invalid Input
City  
Invalid Input
State  
Invalid Input
Zip code  
Number and dashes are acceptable input
Employment started -- 
Invalid Input
Employment ended -- 
Invalid Input
Starting salary  
Invalid Input
Ending salary  
Invalid Input
Job title  
Invalid Input
Supervisor name and title  
Invalid Input
Briefly describe duties  
Invalid Input
Specific reason for leaving  
Invalid Input
Work history two  
Company  
Invalid Input
Company phone
i.e. 123-456-7890
 
Phone number format: 123-456-7890
Address  
Invalid Input
City  
Invalid Input
State  
Invalid Input
Zip code  
Number and dashes are acceptable input
Employment started -- 
Invalid Input
Employment ended -- 
Invalid Input
Starting salary  
Invalid Input
Ending salary  
Invalid Input
Job title  
Invalid Input
Supervisor name and title  
Invalid Input
Briefly describe duties  
Invalid Input
Specific reason for leaving  
Invalid Input
   
Work History & App. Finish 
Work history three  
Company  
Invalid Input
Company phone
i.e. 123-456-7890
 
Phone number format: 123-456-7890
Address  
Invalid Input
City  
Invalid Input
State  
Invalid Input
Zip code  
Number and dashes are acceptable input
Employment started -- 
Invalid Input
Employment ended -- 
Invalid Input
Starting salary  
Invalid Input
Ending salary  
Invalid Input
Job title  
Invalid Input
Supervisor name and title  
Invalid Input
Briefly describe duties  
Invalid Input
Specific reason for leaving  
Invalid Input
Work history four  
Company  
Invalid Input
Company phone
i.e. 123-456-7890
 
Phone number format: 123-456-7890
Address  
Invalid Input
City  
Invalid Input
State  
Invalid Input
Zip code  
Number and dashes are acceptable input
Employment started -- 
Invalid Input
Employment ended -- 
Invalid Input
Starting salary  
Invalid Input
Ending salary  
Invalid Input
Job title  
Invalid Input
Supervisor name and title  
Invalid Input
Briefly describe duties  
Invalid Input
Specific reason for leaving  
Invalid Input
----------------------------------------- 
 
May we contact
previously employers(*)
 
Select answer
List employers you do not
wish us to contact and why
 
Invalid Input
For any appliation information
you provided, have you used a
differen name in the past(*)
 
Select answer
Provide name or names you
used and the organization(*)
 
Provide the name or names
used and the organization
Briefly list any additional skills
or training you may have
 
Invalid Input
Applicant's Statement
LINK(*)
 
You must agree to the Applicant's Statement
to submit your application.