Submit
Print Form
Employment Application
Your Contact Information
First Name
Middle Name
Last Name
Present Address
City
State
Zip
E-mail Address
Phone
Referred By
Which position are you applying for?
Ever worked for this company before?
Yes
No
Date you can start
-
Month
-
Day
Year
Date
Salary Desired
Are you currently employed?
Yes
No
If so, may we inquire your present employer?
Yes
No
Do you have a valid driver"s license?
Yes
No
Issued where?
Issued when?
-
Month
-
Day
Year
Date
Is your vehicle covered by insurance?
Yes
No
Back
Next
Education History
High School
Did you graduate?
Please Select
Diploma
GED
Did not graduate
University/College
Years attended
Type of degree
Major
Trade/Business School
Years
Type of degree
Major
General Information
Subjects of special study/ research work or special training/skills
US military or naval service
Rank
I certify that the facts in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
I also understand that employment with Provide Care, Inc. is dependent upon completion of a criminal background check and passing a pre-employment drug screening.
Signature
Date
-
Month
-
Day
Year
Date
Back
Next
Authorization to Release Information
I authorize Provide Care, Inc. to investigate my current or previous employment and academic experience/qualifications.
I authorize the release to Provide Care, Inc. of any information from my personnel file concerning my job performance, reputation, and character that is pertinent to my potential employment. This includes but is not limited to: written employee evaluations conducted prior to my separation of employment and my written responses, written disciplinary warnings and actions in the 5 years
prior to the date of this authorization and my written responses, and written reasons for my separation from employment.
I hereby release all previous employers, individuals, or institutions including Provide Care, Inc. from any and all liability whatsoever that might be incurred in furnishing such information. I understand that consideration for employment is conditioned upon the results of these reference checks.
I understand that if hired by Provide Care, Inc., I authorize release of my entire personnel file to county social service agencies/and MN Dept. Of Human Services for the purpose of fulfilling licensing requirements.
A copy of this signed release shall have the same force and effect as the original release signed by me and is valid for up to two months from the date below.
Name of Applicant
Applicant Signature
Date
-
Month
-
Day
Year
Date
Job History
Company name
Complete mailing address
Phone
Starting date
-
Month
-
Day
Year
Date
Ending date
-
Month
-
Day
Year
Date
Salary
Position
Resignation
Please Select
Voluntary
Involuntary
Company name
Complete mailing address
Phone
Starting date
-
Month
-
Day
Year
Date
Ending date
-
Month
-
Day
Year
Date
Salary
Position
Resignation
Please Select
Voluntary
Involuntary
Company name
Complete mailing address
Phone
Starting date
-
Month
-
Day
Year
Date
Ending date
-
Month
-
Day
Year
Date
Salary
Position
Resignation
Please Select
Voluntary
Involuntary
Company name
Complete Mailing Address
Phone
Starting date
-
Month
-
Day
Year
Date
Ending date
-
Month
-
Day
Year
Date
Salary
Position
Resignation
Please Select
Voluntary
Involuntary
Back
Next
Applicant Survey
Provide Care, Inc., asks that you voluntarily provide the following information to enable us to monitor our recruitment
activities and be able to report as required by Federal and State Laws. The data on this sheet will be kept in a private file separate from your application.
Personal Information
Position applied for:
Date
-
Month
-
Day
Year
Date
Sex
Female
Male
Age group
16 - 18
19 - 39
40 and over
Race
White
Black
Hispanic
American Indian or Alaskan Native
Asian or Pacific Islander
Veterans Status
Are you a veteran?
Yes
No
If yes, a Vietnam era veteran?
Yes
No
If yes, a disabled veteran?
Yes
No
Disability Status
An individual with a Disability is defined as: any person who has a physical, sensory or mental impairment which
"materially" (State) or "substantially" (Federal) limits one or more major life activity or has a record of or is regarded as having such an impairment
Are you disabled?
Yes
No
If yes, what is your disability?
Other
How did you learn about this job?
Please Select
Employment Agency
Newspaper
Internet
School
Walk-in
From a Provide Care Employee
Contacted Provide Care Human Resources
Other
Name of contact
Back
Next
First Name
Last Name
SITES
(Provide Care, Inc. has Adult Foster homes in each of the cities listed below.
Please number them 1-5 in order of where you would prefer to work).
Rush City/Pine City Area
Cambridge Area
Wyoming Area
North Branch Area
Lindstrom/Center City Area
**Shifts during the weekdays normally begin at 2 or 3pm and end as late as 11pm.
Weekend shifts can begin as early as 8am and end as late as 11pm.**
I am interested in PART time employment. (Part time positions normally consist of working 1-2 shifts during the week and every other weekend 12-14 hour shifts.)
Yes
No
I am interested in FULL time employment.
Yes
No
I am interested in working awake overnights. (This shift begins before midnight and ends around 8:30am)
Yes
No
I am available to work these days/times:
Monday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Monday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Tuesday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Tuesday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Wednesday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Wednesday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Thursday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Thursday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Friday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Friday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Saturday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Saturday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Sunday starting:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Sunday ending:
Please Select
Not available
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Community Based Services
(Provide Care, Inc. has cases located in each of the
counties listed below. Please number them 1-3 in order of where you prefer to work).
Chisago County
Pine County
Isanti County
Back
Next
Waivered Service Staff Questionnaire To Be completed with Application
First Name
Last Name
Date
-
Month
-
Day
Year
Date
What were your responsibilities and duties at your last job?
What parts of your job did you like best? Worst?
Other than money, what rewards, benefits, or work situations are the most important to you? What do you look for in a job?
Describe one obstacle of frustration on your last /current job that you were able to work out.
Back
Next
How would you describe yourself?
Tell me about the most difficult message/communication you"ve ever had to discuss with a co-worker or supervisor and why it was difficult? How did it turn out?
Describe what "teamwork" means to you. Give me some examples of things you"ve done to try to be a good team member or to improve teamwork.
When working with others, what kind of individuals do you find the most difficult to work with? How do you cope with this type of person?
Back
Next
When you left your last employers, were you in a disciplinary process? If yes, please explain.
Have you ever been a Foster Care Provider/Respite Care Provider in your own home?
Yes
No
May I talk to your past employers for a reference?
Yes
No
Submit
Should be Empty: