Online Application

Please print and complete all requested information. Applicants may be asked to provide additional information on separate forms.

APPLICANT INFORMATION

Date:

Are you 18 Years of age or older?YesNo

Are you legally eligible to be employed in the United States?YesNo

Have you been charged or convicted of a felony/ misdemeanor or know of any other reason you might not pass the mandatory criminal background check? (According to the MN Department of Human Services all potential candidates must pass a criminal background check before employment may be offered)
YesNo

Position desired*:

Desired hours per week*:

Date available to begin work:

Shifts	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
From
To

Have you ever worked with Home Health Care? YesNo

Were you referred by a PCA or a client? YesNo

Are you presently working with another home health care company? YesNo

Are you applying to work with a specific client?

Are you currently employed?YesNo

If yes may we contact your employer?YesNo

EMPLOYMENT HISTORY

(PLEASE START WITH YOUR RECENT EMPLOYER)

Company Name: *

Supervisor’s name: *

Telephone: *

Position and Duties:: *

Dates of Employment:

From *

to*

Starting pay: *

Ending Pay:*

Reason for Leaving: *

Company Name: *

Supervisor’s name: *

Telephone: *

Position and Duties:: *

Dates of Employment:

From *

to*

Starting pay: *

Ending Pay:*

Reason for Leaving: *

Company Name: *

Supervisor’s name: *

Telephone: *

Position and Duties:: *

Dates of Employment:

From *

to*

Starting pay: *

Ending Pay:*

Reason for Leaving: *

Do you have any other experience, training, qualifications or skills which you feel make you especially suited to work for Home Health Care?
If so, please explain

EMPLOYMENT HISTORY

(PLEASE START WITH YOUR RECENT EMPLOYER)

Please list below three professional references. Professional references are individuals who can attest to your work performance in a professional or academic setting such as a direct supervisor, colleague, academic advisor or a professor.

Name: *

Occupation: *

Address: *

Telephone: *

Number of years acquainted: *

Name: *

Occupation: *

Address: *

Telephone: *

Number of years acquainted: *

Name: *

Occupation: *

Address: *

Telephone: *

Number of years acquainted: *

School	Name and address	No. of years completed	Did you graduate?	Degree or diploma
Junior high			YesNo	Degreediploma
High school			YesNo	Degreediploma
College/University			YesNo	DegreeDiploma
Vocational/Business			YesNo	DegreeDiploma
Other			YesNo	DegreeDiploma

APPLICANT INFORMATION

EMPLOYMENT DESIRED

EMPLOYMENT HISTORY

EDUCATION HISTORY

EMPLOYMENT HISTORY

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