| HOME RENTAL APPLICATION PART 1: PLEASE ENTER THE PROPERTY ADDRESS YOU WHICH TO RENT HERE>> | |
| First Name | |
| Middle Name | |
| Last Name | |
| Address Line 1 | |
| Address Line 2 | |
| City | |
| State | |
| Zip Code | |
| Daytime Phone | () - |
| Evening Phone | () - |
| E-mail Address | |
| DL # / State / Type | |
| PERMANENT ADDRESS: | |
| City / State / Zip Code | |
| SS# in the format (xxx-xx-xxxx) / County of Resident: | |
| ARE YOU OVER 18 of age? and ARE YOU A CITIZEN OF THE U.S.? Please Answer YES or NO TO BOTH QUESTIONS: | |
| IN CASE OF EMERGENCY, WHO SHOULD WE CONTACT?: | |
| ADDRESS OF EMERGENCY CONTACT? | |
| Emergency Contact City / State / Zip Code | |
| LICENSURE RULES AND REGULATIONS REQUIRE THAT INDIVIDUALS PROVIDING DIRECT CARE AND INTERACTION WITH VULNERABLE CLIENTS MUST NOT HAVE BEEN CONVICTED OF CRIMES AGAINST PERSONS. HAVE YOU EVER BEEN CONVICTED OF CRIMINAL OFFENSES SUCH AS HOMICIDE, CRIME AGAINST A PERSON, CRIMES OF COMPULSION, SEX CRIMES, INCEST, THEFT, BURGLARY, ARSON, OR OBSCENE PHONE CALLS? Please Answer YES or NO: | |
| IF YES, STATE THE OFFENSE, LOCATION, DATE AND DISPOSITION: | |
| **I UNDERSTAND THAT IF I AM HIRED, MY CONTINUED EMPLOYMENT MAY DEPEND UPON VERIFICATION OF NO CRIMINAL BACKGROUND. THIS IS VERIFIED THROUGH A BUREAU OF CRIMINAL APPREHENSION (BCA) CHECK AND OR MINNESOTA DEPARTMENT OF HUMAN SERVICES. SPECIFIC INFORMATION WILL BE REQUIRED OF ME IN ORDER TO PROCESS THE BCA CHECK. I ALSO UNDERSTAND THAT MY CONTINUES CONTRACT IS DEPENDEDNT ON MY POSITIVE PROBATIONAL REVIEW THAT LAST FOR THREE MONTHS. | |
| Please enter the position(s) you are applying for: Available ones are : ___RN ___LPN ___ CNA or NAR ____PCA ____LSW ___ HHA ____Homemaker ___ PhTECH ___ Pharmacist ___ STAFFING ____ Other. To Acknowledge, Please Enter the requested information to the right of here >> | |
| In Homecare, hours of work will vary. Do you have flexibility in your schedule? Pleae answer Yes or No | |
| ARE YOU SEEKING: Regular Full-Time, Regular Part-Time, Regular or Temporary Summer or Winter Employment? Please Enter the requested information to the right of here >> | |
| Please specify what days and hours you are available to work To Acknowledge, Please Enter the requested information to the right of here >> | |
| Please specify all the hours are you available to work to the right of here >> | |
| HAVE YOU EVER APPLIED TO THIS COMPANY BEFORE? PLEASE ANSWER YES or NO | |
| HAVE YOU EVER WORKED FOR THIS COMPANY BEFORE? PLEASE ANSWER YES or NO: | |
| IF YES TO THE ABOVE, PLEASE STATE WHEN AND WHERE YOU APPLIED AND/OR WORKED: | |
| HOW DID YOU HEAR ABOUT THIS COMPANY? | |
| ARE ANY RELATIVES CURRENTLY HIRED BY THIS COMPANY? PLEASE ANSWER YES or NO: | |
| IF YES, WHO? : | |
| EDUCATION: NAME OF HIGH SCHOOLS ATTENDED / ADDRESS/ LOCATION / DATES | |
| CONTINUE NAME OF HIGH SCHOOL INFO.: | |
| NAME OF COLLEGE #1 ATTENDED / ADDRESS/ LOCATION / DATES | |
| CONTINUE NAME OF COLLEGE #1 ATTENDED INFO | |
| NAME OF COLLEGE #2 ATTENDED / ADDRESS/ LOCATION / DATES | |
| CONTINUE NAME OF COLLEGE #2 ATTENDED INFO: | |
| NAME OF TRADE SCHOOL ATTENDED / ADDRESS/ LOCATION / DATES | |
| CONTINUE NAME OF TRADE SCHOOL ATTENDED INFO: | |
| ARE YOU PLANNING TO PURSUE FURTHER EDUCATION? PLEASE ANSWER YES or NO: | |
| IF YES TO THE ABOVE QUESTION, PLEASE SPECIFY WHEN, WHERE, AND WHAT COURSES: | |
| MILITARY : HAVE YOU EVER SERVED IN THE MILITARY? PLEASE ANSWER YES or NO: | |
| ARE YOU A MEMBER OF A RESERVED ORGANIZATION? PLEASE ANSWER YES or NO: | |
| SERVICE BRANCH & DATE ENTERED: | |
| DATE DEPARTED & FINAL RANK : | |
| HEALTH : PER LICENSING REGULATIONS, APPLICANTS MAY BE REQURED TO BE CERTIFIED FREE OF COMMUNICABLE DISEASES. DO YOU HAVE A CURRENT NEGATIVE MANTOUX TEST OR X-RAY OR TB GOLD TEST (WITHIN THE PAST 7 DAYS)? PLEASE ANSWER YES or NO | |
| HAVE YOU EVER BEEN INJURED ON THE JOB OR ANY JOB? PLEASE ANSWER YES or NO: | |
| IF YES TO THE ABOVE QUESTION, PLEASE DESCRIBE INCIDENT #1: | |
| NATURE OF INJURY #1: | |
| EMPLOYER AT THE TIME OF INJURY #1: | |
| NUMBER OF DAYS LOST AS A RESULT OF INJURY #1: | |
| MONTH/DAY/YEAR OF INJURY #1: | |
| PLEASE DESCRIBE INCIDENT #2 IF ANY: | |
| NATURE OF INJURY #2 IF ANY: | |
| EMPLOYER AT THE TIME OF INJURY #2: | |
| NUMBER OF DAYS LOST AS A RESULT OF INJURY #2: | |
| MONTH/DAY/YEAR OF INJURY #2: | |
| DO YOU HAVE ANY PRE-EXISTING MEDICAL CONDITION THAT WILL PREVENT YOU FROM WORKING FOR THIS COMPANY ? PLEASE ANSWER YES or NO | |
| IF YOUR ANSWER IS YES TO THE ABOVE QUESTION, PLEASE EXPLAIN: | |
| WILL YOU ABIDE BY THE SAFETY RULES OF THIS COMPANY? PLEASE ANSWER YES or NO: | |
| CONFIRM PRIVACY NOTICE : I am the subject of this background study, and I confirm I have reviewed the privacy notices listed above . To Acknowledge, Please Enter your Initials to the right of here>> | |
| CONFIRM PRIVACY NOTICE : I Authorize this company to initiate background study on my behalf, and I confirm that the privacy notice listed on the Employment Application website has been provided to me, the subject of the background study. To Acknowledge, Please Enter your initials to the right of here >> | |
| DISCLAIMER AND SIGNATURE 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. To Acknowledge, Please Enter your initials to the right of here >> | |
| SIGNATURE (PLEASE SIGN BY TYPING IN YOUR LEGAL FULL NAME FOLLOWED BY THE LAST 4 DIGITS OF YOUR SOCIAL SECURITY NUMBER, AND ALL YOUR INITIALS AND TODAY’S DATE. To Acknowledge, Please Enter the requested information to the right of here >> | |
| Date application completed. To Acknowledge, Please Enter the requested information to the right of here >> | |
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