Reliable Home Care MN Application Form

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

This application will be kept on an active status for a period of 60 days. It is the applicants’ responsibility to periodically check and update their application. All applicants will be required to complete this employment application to be considered for an open position with Reliable Home Care MN A resume will not substitute for a completed employment application.

RELIABLE HOME CARE MN IS AN EQUAL OPPORTUNITY EMPLOYER. WE ENCOURAGE ALL QUALIFIED INDIVIDUALS TO APPLY FOR EMPLOYMENT.

* Required Field

APPLICANT INFORMATION

Date:

Full Name:

Last Name:
*

First Name:
*

Middle Name:

Address:

Street:

City:

State:

Zip:

Phone:

E-mail:

Are you 18 Years of age or older?Yes No

Are you legally eligible to be employed in the United States?Yes No

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)
Yes No

EMPLOYMENT DESIRED

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 Reliable Home Care MN? Yes No

Were you referred by a PCA or a client? Yes No

Are you presently working with another home health care company? Yes No

Are you applying to work with a specific client?

Are you currently employed? Yes No

If yes may we contact your employer? Yes No

EMPLOYMENT HISTORY

(PLEASE START WITH YOUR RECENT EMPLOYER)

Company Name: *
Company address: *
Supervisor’s name: *
Telephone: *
Position and Duties: *
Dates of Employment: From *	to*
Starting pay: *	Ending Pay:*
Reason for Leaving: *

Company Name:
Company address:
Supervisor’s name:
Telephone:
Position and Duties:
Dates of Employment: From	to
Starting pay:	Ending Pay:
Reason for Leaving:

Company Name:
Company address:
Supervisor’s name:
Telephone:
Position and Duties:
Dates of Employment: From	to
Starting pay:	Ending Pay:
Reason for Leaving:

EDUCATION HISTORY

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

Do you have any other experience, training, qualifications or skills which you feel make you especially suited to work for life fountain home health care, Inc?

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:

ACKNOWLEDGMENT

Conditions of Employment

The above information is true and correct. I understand that, in the event of my employment, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herine requested, regardless of the time elapsed after discovery. I authorize Reliable Home Care MN to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to Reliable Home Care MN I will hold Reliable Home Care MN, and my former employer, harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize Reliable Home Care MN to obtain any credit and consumer check. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with Reliable Home Care MN is intended to create an employment contract between myself: and Reliable Home Care MN, and that my employment could be terminated only for cause. On the contrary, I understand and agree that, if hired, my employment will be terminable at will, and may be terminated by me (with the reasonable 2 week notice) or Reliable Home Care MN at any time, and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9.

Print Name:

Date:

Conditions of Employment

Due to the nature of our business it is required that each person pass a criminal background check before he/she is offered a position with Reliable Home Care MN The background check may take 5-7 business days or in some cases several weeks. If during the course of your employment we receive a letter from the MN Department of Human Services stating that you are no longer eligible to work in the field of Human Services or that if you remain employed you must remain supervised at all times we will terminate employment immediately. Due to the nature of our business and in order to best meet the needs of our clients, Reliable Home Care MN and the MN Department of Human Services require staff members to have and maintain cleared background checks in order to be eligible for continued employment.

Print Name:

Date: