* = Required Information

Applicant Name (print): *		Date of Application: *

Company: Comfort Care Resource Group
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.
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.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by Massachusetts state Laws and regulations. I understand that I have the right to:

Review information provided by previous employer; and
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Date: *

APPLICANT TO COMPLETE
Position(s) Applied for
Name		Social Security Number
	Last First Middle

List your addresses of residency for the past 3 years.
Current Address
	Street City
	Phone How Long? Street City State & Zip Code
	Phone How Long? Street City State & Zip Code
	Phone How Long? Street City State & Zip Code
	Phone How Long? Street City State & Zip Code

Do you have the legal right to work in the United States?
Date of Birth
Can you provide proof of age?
Have you worked for this company before?
Where?
Dates:	From To
Rate of Pay
Position
Reason for leaving
Are you now employed?
If not, how long since leaving last employment?
Who Referred you?
Rate of pay expected?
Have you ever been bonded?
Name of bonding company?
Have you ever been convicted of a felony?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER	DATE
Name *
Address *
City *
Contact Person *
Were you subject to the FMCSRs while employed YesNo
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? YesNo

EMPLOYER	DATE
Name
Address
City
Contact Person
Were you subject to the FMCSRs while employed YesNo
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? YesNo

EMPLOYER	DATE
Name
Address
City
Contact Person
Were you subject to the FMCSRs while employed YesNo
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? YesNo

EMPLOYER	DATE
Name
Address
City
Contact Person
Were you subject to the FMCSRs while employed YesNo
Was your job designated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? YesNo

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weights or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident record for past 3 years or more (attach sheet if more space is needed) if none, write none

DATES	NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ECT)	FATALITIES	INJURIES	HAZARDOUS MATERIALS SPILL

Traffic convictions and forfeitures for the past 3 years (other than parking violations) if none, write none

LOCATION	DATE	CHARGE	PENALTY

EXPERIENCE AND QUALIFICATIONS – DRIVER

List all driver licenses or permits held in the past 3 years

DRIVER LICENSES	STATE	LICENSE NO.	TYPE	EXPIRATION DATE

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?	YesNo
B. Has any license, permit or privilege ever been suspended or revoked?	YesNo
If the answer to either A or B is yes, give details

DRIVING EXPERIENCE CIRCLE YES OR NO

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT	DATES FROM (M/Y) TO (M/Y)	APPROX. NO. OF MILES(TOTAL)
Nemt vehicle YesNo
Ambulance YesNo
Motorcoach – school bus (More than 8 ) YesNo
OTHER

List states operated in for last five years:

Show special courses or training that will help you as a driver

Which safe driving awards do you hold and from whom?

EXPERIENCE AND QUALIFICATIONS – OTHER
Show any trucking, transporting or other thank shown elsewhere in this application

List courses and training other than shown elsewhere in this application

List special equipment or technical materials you can work with (other than those already shown)

EDUCATION
Circle highest grade completed:	12345678
High school:	1234
College:	1234
Last school attended:
Name:
City/State:
TO BE READ AND SIGNED BY APPLICANT
* This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Date:

* Security Code