* = Required Information
Last Name * Middle Initial * First Name * SSN# *
Current Address * City *
State * Zip Code * APT Date of Birth:
Gender *MaleFemale Marital Status * MarriedSingle
Phone #: * Email Address: *
Auto Ins. Policy #: Issue Date:
Driver's Lic. / State ID * Expiration Date:
AA/EEO CODE *
African American/ Black Asian/ Pacific Islander Caucasian
Disabled/ Handicapped Hispanic/ Latin American Native American
Other Unknown
What Position You Are Applying For?


AVAILABILITY

Please mark all of the hours you are available for work. Please indicate am or pm
 
 
Start Time *

End Time *
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
On what date would you be able to start work? * Are you currently employed? YesNo
Have you filled out an application with us before? YesNo If yes, give date:
Have you been employed with us before? * YesNo If yes, give date:
Available for: TemporaryPart-TimeFull-Time

EMERGENCY CONTACT
Name * Address * City *
State * Zip Code * County *
Contact Number: *
How did you hear about us? (Please check all that apply) *
Employment Agency Advertisement
Walk-in Friends or Relatives
If so, Name:

EMPLOYMENT EXPERIENCE
Please start with your most recent job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, gender, national origin, handicap, or other protected status
Employer Name
Address *
City * State Zip *
Country *
Tel. # 1: * Tel. # 2:
Job Title *
Supervisor *
Reason for Leaving
Dates Employed
From To
Hourly Rate/ Salary
Start Final
May we contact? YesNo

Employer Name
Address
City State Zip Code
Country
Tel. # 1: Tel. # 2:
Job Title
Supervisor
Reason for Leaving
Dates Employed
From To
Hourly Rate/ Salary
Start Final
May we contact? YesNo

Employer Name
Address
City State Zip Code
Country
Tel. # 1: Tel. # 2:
Job Title
Supervisor
Reason for Leaving
Dates Employed
From To
Hourly Rate/ Salary
Start Final
May we contact? YesNo
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration will be required upon employment) *
YesNo
Have you been convicted of a felony within the last 7 years? (Including sex related or child related offenses? YesNo
If yes, please explain:

EDUCATION
HIGH SCHOOL
School Name * Years Completed *
9101112
Address/ Location * Graduated?
YesNo
Describe course of study:
COLLEGE/ VOCATIONAL
School Name * Years Completed *
9101112
Address/ Location * Graduated?
YesNo
Describe course of study:
ADDITIONAL TRAINING AND SPECIALIZATION SKILLS
Please list in-service training, job related skills or special certificates below: (E.g.: CPR, First Aid, Behavior Management, etc.)

REFERENCES
Please provide the name, address, and telephone number of three references who are not related to you
Name *   
Address *
City * State * Zip Code *
Telephone #: * Describe Relationship to you: *

Name *    
Address *
City * State * Zip Code *
Telephone #: * Describe Relationship to you: *

Name    
Address
City State Zip Code
Telephone #: Describe Relationship to you:

TO ALL APPLICANTS
Caringhands Home Health Care is an "AT WILL" employer. "AT WILL" means employees have the right to end their employment without notice. Also, the company reserves the right to terminate employment without reason or notice. This does not include any person who holds contracts for employment or any unfair employment practices.
Signature Date
If you are considered for employment, you must meet and sustain the following criteria:
Provide 3 references that must be checked before hire YesNo
Must possess a valid driver's license: YesNo
Possess a vehicle to use at and for work at all times: YesNo
Have automobile insurance YesNo
Clear a criminal background check: YesNo

Driving record checks and background studies are done for all new hires and current employees yearly. Both checks must be rated with a 'CLEAR' status or termination will result. The Department of Human Services requires three reference checks. Employees will have ten (10) days to get these completed or termination will result.
PLEASE NOTE
EMPLOYMENT OR CONTINUED EMPLOYMENT IS CONTINGET ON ALL FACTORS ABOVE

New Employee training is mandatory (4) hours of training are required by the State of Minnesota and the Department of Human Services. No employee may work at any home until orientation and on-site training (Care Plan) has been reviewed by the RN or Qualified Person.
We require that all applicants to complete the new training within two (2) weeks of their hire date (or the first available training class).
I accept this training completion notice and I am able to complete my training in a (2) week period. All training and meetings are paid at minimum wage. This includes all on-going training.
I accept this training completion notice but I am unable to complete my training in the two (2) week period. I understand that training is mandatory and I can complete my training in (time)
Applicants Signature Date Date

CHILD SUPPORT DISCLOSURE FORM
Employee Name: Date of Birth:
Address: SSN #:
City State Zip Code
County

Minnesota State Law requires individuals to disclose information about court-ordered child support obligations when they are hired for employment (Minn. Stat. S 518.611, SUBD. 8
Please answer the following as required by law:
DO YOU OWE COURT-ORDERED CHILD SUPPORT THAT YOUR EMPLOYER IS REQUIRED TO WITH HOLD FROM YOUR INCOME?
If you answered "yes" you must provide the following information for each obligation:
Amount Owed: PER For current support
Amount Owed: For arrearages
Date of the court order: For arrearages

Name and birthdates of child(ren) for whome support is owed:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Child Support agency where support is to be sent:
Employee Name: Address
City State
Zip Code Your support account #:
I declare that everything I have stated on this form is complete and correct to the best of my knowledge. I hereby authorize my employer to verify the information provided with the public agency responsible for child support enforcement.
PERSUANT TO MINNESOTA STATE STATUTE 518.611, SUBDIVISION 8, all Minnesota employers must ask persons hired on or after August 01, 1987, the following questions:
Do you have court-ordered child support obligations which are required by law to be withheld from income? YesNo
If yes, you must disclose the terms of the order including:
Which Minnesota Child Support Agency should receive payment?
Amount Due Frequency
Date of the court order: County where order originated:
Employer's Name