Employment Application

Education History
High School
Did you 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*

MonthDayYear
Date

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*

MonthDayYear
Date
Job History
Company name
Complete mailing address
Phone
Starting date

MonthDayYear
Date
Ending date

MonthDayYear
Date
Position
Resignation

Company name
Complete mailing address
Phone
Starting date

MonthDayYear
Date
Ending date

MonthDayYear
Date
Position
Resignation
Company name
Complete mailing address
Phone
Starting date

MonthDayYear
Date
Ending date

MonthDayYear
Date
Position
Resignation
Company name
Complete Mailing Address
Phone
Starting date

MonthDayYear
Date
Ending date

MonthDayYear
Date
Position
Resignation

Sites - Provide Care, Inc. has Adult Foster homes in each of the cities listed below.Please number them 1 through 5 in order of where you would prefer to work. (1 most preferred to 5 least preferred)
Rush City/Pine City Area
Cambridge Area
Wyoming Area
North Branch Area
Lindstrom/Center City Area
**Shifts during the week begin in the early afternoon hours and end as late as 11pm.

We DO NOT have 8am-4pm shifts available in our houses.

Weekend shifts can begin as early as 8am and end as late as 11pm.**

Working every other weekend is a requirement for all positions. Shifts are subject to change based on the needs of the site and the individuals who reside there.
I have read and understand the information above regarding shift schedules.*

Yes
I am interested in PART time EVENING SHIFT employment. (Part time positions normally consist of working 1-2 shifts during the week and every other weekend 12-14 hour shifts.)

YesNo
I am interested in FULL time EVENING SHIFT employment. (Full time positions normally consist of working 3-4 shifts during the week and every other weekend 12-14 hour shifts.)

YesNo
I am interested in working FULL time AWAKE OVERNIGHTS. (This shift begins before midnight and ends around 8:30am)

YesNo
I am available to work these days/times: (note- must be either PT/FT evening shift OR overnight, we cannot accomodate alternating)
Monday:*
Tuesday:*
Wednesday:*
Thursday:*
Friday:*
Saturday:*
Sunday:*

Direct Support Professional Questionnaire To Be completed with Application (REQUIRED)
First Name
Last Name
Date

MonthDayYear
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.
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?
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?

YesNo
May I talk to your past employers for a reference?

YesNo
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