Personal InformationName(Required) First Middle Initial Last Do you go by another name? If yes, please indicateDOB(Required) MM slash DD slash YYYY Present Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address different from your Drivers License?(Required) Yes No If yes, please put your mailing address down below:Permanent Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)Email Address(Required) Date Available(Required) MM slash DD slash YYYY Social Security No(Required)Position Applying for(Required)Are you a citizen of the United States?(Required) Yes No Are you authorized to work in the U.S.?(Required) Yes No Have you ever worked for this company?(Required) Yes No If yes, when?Have you ever been convicted of a felony?(Required) Yes No If yes, explainAre you willing to complete a drug test?(Required) Yes No Have you lived in any other state, other than Minnesota, in the last 5 years?(Required) Yes No If yes, where?ClientsAre you coming in with a client?(Required) Yes No If you are coming in with a client, are in interested in other clients? Yes No Client nameClient Phone NumberPreferencesAre you willing to work with:(Required) Male Clients Female Clients Both Are you willing to work with pets?(Required) Yes No If yes, which ones? Cats Dogs Other Are you willing to work clients who smoke?(Required) Yes No Anything else we should know about your preferences?Available LocationsHow many miles are you willing to travel from home?(Required)What locations can you cover? (Please check all that apply)Saint Paul East West Minneapolis North South If others, please listAvailabilityAvailability(Required) Full Time Part Time Please select the days you will be available for work, and select your time preferences.Monday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM Tuesday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM Wednesday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM Thursday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM Friday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM Saturday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM Sunday(Required)AvailableNot AvailableFrom Hours : Minutes AM PM AM/PM To Hours : Minutes AM PM AM/PM TransportationDo you have a car?(Required) Yes No If not, how will you be traveling?EducationHigh School(Required)Address(Required)DiplomaFrom(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Did you graduate?(Required) Yes No CollegeAddressDegreeFrom MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate? Yes No OtherAddressDegreeFrom MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate? Yes No ReferencesName First Last RelationshipCompanyPhoneAddressName First Last RelationshipCompanyPhoneAddressName First Last RelationshipCompanyPhoneAddressPrevious EmploymentCompanyPhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason for LeavingMay we contact your previous supervisor for reference? Yes No CompanyPhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason for LeavingMay we contact your previous supervisor for reference? Yes No CompanyPhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason for LeavingMay we contact your previous supervisor for reference? Yes No Military ServiceBranchFrom MM slash DD slash YYYY To MM slash DD slash YYYY Rank at DischargeType of DischargeIf other than honorable, explainLanguageWhat languages do you speak, read, or write fluently?Language Denial You can choose to deny answering this question by checking this box.Disclaimer and SignatureCertification(Required) Certification(Required)I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Signature(Required)Type your name hereToday's Date(Required) MM slash DD slash YYYY Background StudyBackground Study Consent(Required) Background Study Consent(Required)I hereby authorize Best Care Home Health to conduct a background study on me as part of the employment process. This includes, but is not limited to, a criminal history check, employment verification, and education verification. I understand that the results of this study will be used for employment purposes only, and will be kept confidential. I understand that I may request a copy of the background study report by contacting Best Care home Health in writing within 60 days of receiving the report. I certify that all of the information provided on this form is true and complete to the best of my knowledge.Signature(Required)Type your name hereToday's Date(Required) MM slash DD slash YYYY Please note that by signing this form, you are authorizing Best Care Home Health to conduct a background study on you as part of the employment process. The results of this study will be kept confidential and used for employment purposes only. If you have any questions or concerns about this process, please contact Best Care Home Health for more information.Background Study Fee(Required) Price: Payment Method(Required) Credit Card Paid through Office Credit Card(Required)
