Employment Application

POSITION APPLYING FOR (PCA, HMK, HHA, RN, LPN): *

EMAIL ADDRESS: *

FIRST NAME (First): *

MIDDLE NAME (Middle): *

LAST NAME (Last): *

HAVE YOU USED ANY NAMES OTHER THAN GIVEN ABOVE? *

IF YES, PLEASE LIST

STREET ADDRESS *

Apt #

CITY *

STATE *

COUNTY *

ZIP *

CELL PHONE: *

HOME PHONE:

ARE YOU OVER THE AGE OF 18?: *

DATE OF BIRTH?: *

SOCIAL SECURITY NUMBER?: *

HAVE YOU LIVED OUTSIDE OF MINNESOTA IN THE PAST 5 YEARS? *

IF YES, PLEASE INDICATE THE STATE, AND YEARS OF WHERE YOU LIVED IN THE PAST 5 YEARS.:

PLACE OF BIRTH (State/Country)?: *

EMERGENCY CONTACT (Name, Phone Number, Relationship)?: *

HOW DID YOU HEAR ABOUT US?: *

HAVE YOU EVER WORKED FOR ABOUT U BEFORE? *

HAVE YOU EVER BEEN A MEMBER OF THE ARMED FORCES? *

IF YES, WHAT BRANCH?

ARE YOU PRESENTLY A GUARDS OR RESERVE MEMBER?

WORK AVAILABILITY:

PART TIME: *

FULL TIME: *

DAYS AND TIMES YOU ARE AVAILABLE TO WORK:

ARE YOU ALLERGIC TO CIGARETTE SMOKE?: *

DO YOU HAVE ANY PET ALLERGIES OR PET PHOBIAS?: *

RELIABLE MEANS OF TRANSPORTATION

IF THE JOB REQUIRES, DO YOU HAVE THE APPROPRIATE VALID DRIVERS LICENSE? *

IF NO, WHAT IS YOUR RELIABLE FORM OF TRANSPORTATION?

STATE OF ISSUE? *

HAVE YOU EVER HAD ANY MOVING VIOLATIONS? *

IF YES, PLEASE DESCRIBE

MOST RECENT EMPLOYER INFORMATION

COMPANY NAME *

CITY *

STATE *

PHONE NUMBER *

FAX NUMBER

SUPERVISOR NAME *

DUTIES

SALARY EARNED *

JOB TITLE *

DATES OF EMPLOYMENT *

….REASON FOR LEAVING *

ARE YOU CURRENTLY WORKING FOR THIS EMPLOYER? *

IF YES, MAY WE CONTACT?

ADDITIONAL INFORMATION – WORK EXPERIENCE

DO YOU HAVE EXPERIENCE AS A PCA OR HOMEMAKER *

GIVE EXAMPLE OF THE TYPES OF CARE YOU HAVE WORKED FOR IN THE PAST *

Or, select one of the following?

Hoyer liftTransfer beltRecliner lift chairSlide boardStand up liftsWheelchair manualWheelchair electricBowel ProgramCatheters (empty/clean)

WORK REFERENCE…PLEASE INCLUDE NAME, ADDRESS, PHONE, RELATIONSHIP WITH AND NUMBER OF YEARS KNOWN. NO RELATIVES PLEASE. *

WHAT IS THE HIGHEST GRADE OF EDUCATION YOU COMPLETED? *

HIGH SCHOOL NAME, LOCATION AND SUBJECTS STUDIED *

DID YOU GRADUATE? *

COLLEGE/VOCATIONAL SCHOOL NAME, LOCATION AND SUBJECTS STUDIED

DID YOU GRADUATE?

BY CHECKING THIS BOX I CERTIFY THAT ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. PLEASE READ ALL INFORMATION ABOVE REGARDING THE RELEASE OF THIS INFORMATION. *
I Agree

YOUR NAME AND TODAY’S DATE *