Employment Application

Thank you for your interest in In-Home Comfort Care.

In-Home Comfort Care provides experienced, compassionate care to seniors and their families looking for reliable, trustworthy Caregivers. We receive many inquiries each day from people who are interested in qualifying to be on our In-Home care provider team.

To be considered as a team member with IHCC, the following must be met:

  1. Minimum 2+ years of experience providing care within the industry.
  2. A dependable vehicle properly insured.
  3. Valid State driver’s license.
  4. You must be trustworthy and dependable.

In addition to meeting the above criteria, the following documentation will be required:

  1. Recent copy of your driver’s license report (within last 6 months).
  2. Copy of recent TB (Tuberculosis) screening (within last 6 months).
  3. Background check completed.
  4. Any certifications or degrees you may have earned.
  5. Minimum of 3 verifiable professional references.

If you can meet all of the above, then completely read and fill out the enclosed Application.

When you have completed the Application, please fax, return by mail or drop off at our office listed above.

Thank you for your interest.

In-Home Comfort Care

Caregiver Employment Application

By filling out this application and questionnaire, you are applying for employment at In-Home Comfort Care. This company is dedicated to a policy of non-discrimination of applicants on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

Employment Applications

Contact Information

Do you smoke?

Alternate Contact

Most clients require transportation, often using the Care Provider’s vehicle.
Are you currently employed / provide Care to others?
Have you ever been convicted of a misdemeanor/felony?


Most clients require transportation, often using the Care Provider’s vehicle:
Do you have dependable transportation?


Can you be called at the last minute in case of emergency?

What Education Qualifies You To Work As a Caregiver?

Copies of all Degrees/Certificates must be presented. All will be verified with provider/issuer.
Special skills or courses – Any skills that assist in making you qualified as a professional Care Provider.

What is Your Past Experience?


Please indicate which of the following skills you are prepared to provide if referred to seniors/families.
Companion Care & Safety
Medication Reminders
Oral Care
Companion Care & Safety
Shaving Assistance
Bathing (Reg., bed, sponge)
Assist w / P.T. Exercises
Assist w/ Prosthesis
Meal Prep / Clean Up
Dressing/ Grooming
Meal Prep / Clean Up
Light Housekeeping
Willing to Work w/Pets
Transfer Assist
Speak fluent English

Work History

Please provide at least five years of recent, verifiable work history followed by verifiable references.

Job 1

Job 2

Job 3

Business | Professional References

Character & Personal References

Certification and Release

I certify that I have read and understand the general requirements of Independent Care Contractors/Providers on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application as an interested Care Provider and that by submitting this there is no guarantee for employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.