Minnetonka Assisted Living and Hospice, 14667 Lake Street Extension, Minnetonka, MN 55345 (952)405-6960 Facility (952)456-6466 Fax Minnetonka Assisted Living and Hospice
Employment Application Please print and complete all sections.
Full Name: _________________________________________________________________________________________ Current Address: ____________________________________________________________________________________ City/State/Zip: ______________________________________________________________________________________ Home Phone #: _____________________________________________________________________________________ Other Phone #: _____________________________________________________________________________________ Position applying for (circle one): Home Health Aide Certified Nursing Assistant Registered Nurse
Regular part-time work: Yes or No
Regular Full-time work: Yes or No
Temporary Work: Yes or No
What days and hours are you available? Options (circle all that apply): 7am-3pm 3pm-11pm 11pm-7am If hired, what date can you start working? ________________________________________________________________ Can you work weekends? Yes or No Can you work evenings? Yes or No Salary Desired: _____________________________________________________________________________________ How were you referred to Bubbiesitter and Zadies Too®? _______________________________________
Have you ever applied to/worked for Bubbiesitter and Zadies Too®? Yes or No
If yes, please explain (include dates): ___________________________________________________________________ Do you have any friends or relatives working for Bubbiesitter and Zadies Too®? Yes or No
If yes, state name(s) and relationship(s). ________________________________________________________________ If hired, would you have transportation to and from work? Yes or No
If yes, what type of transportation would be used? ________________________________________________________ Do you drive? Yes or No
If yes, please list driver’s license number, current insurance carrier and policy number: __________________________ _________________________________________________________________________________________________ Are you over the age of 18? (If under 18, hire is subject to verification of legal minimum age.) Yes or No
If hired, would you be able to provide evidence of US Citizenship or proof of legal right to work in the United States? Yes or No
Do you speak, write or understand any languages other than English? Yes or No
Minnetonka Assisted Living and Hospice, 14667 Lake Street Extension, Minnetonka, MN 55345 (952)405-6960 Facility (952)456-6466 Fax Do you have any other experience, training, qualification or skills which you feel should be brought to our attention, in the event that they would make you especially suited for working with Bubbiesitter and Zadies Too®. Yes or
No If yes, please explain: ________________________________________________ If hired, are you willing to submit to and pass a controlled substance test? Yes or No
Are you willing to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation? Yes or No If no, describe the functions which cannot be performed:
__________________________________________________
*(Note: Company complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees/independent contractors to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)
Have you ever been convicted of any criminal offense (felony or misdemeanor?) Yes or No
If yes, please describe the crime(s), the nature of the crime(s) , when and where convicted and disposition of the case: __________________________________________________________________________________________
*(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, the
surrounding circumstances and the relevance of the offense to the position(s) applied for however, may be considered.)
References
List three people (excluding relatives) who have knowledge of your professional work performance within the last four years.
Minnetonka Assisted Living and Hospice, 14667 Lake Street Extension, Minnetonka, MN 55345 (952)405-6960 Facility (952)456-6466 Fax Education, Training and Experience
High School:
Name: ________________________________________________________________ Address: _______________________________________________________________ City/State/Zip: __________________________________________________________ Number of Years Completed: ___________ Did you Graduate? Yes or No (Circle one) Degree / Diploma Earned: _________________________________________________ College:
Name: ________________________________________________________________ Address: _______________________________________________________________ City/State/Zip: __________________________________________________________ Number of Years Completed: ___________ Did you Graduate? Yes or No (Circle one) Degree / Diploma Earned: _________________________________________________ Vocational School:
Name: ________________________________________________________________ Address: _______________________________________________________________ City/State/Zip: __________________________________________________________ Number of Years Completed: ___________ Did you Graduate? Yes or No (Circle one) Degree / Diploma Earned: _________________________________________________ Military:
Branch: ________________________________________________________________ Dates of Service: __________________________________Rank: __________________ Skills/Duties: ____________________________________________________________ Honorable Discharge: Yes or No (Circle one)
Minnetonka Assisted Living and Hospice, 14667 Lake Street Extension, Minnetonka, MN 55345 (952)405-6960 Facility (952)456-6466 Fax Employment History
Please list past and present employment positions, dating back five years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.
Are you currently employed? Yes or No (Circle one)
May we contact your current employer? Yes or No (Circle one)
Minnetonka Assisted Living and Hospice, 14667 Lake Street Extension, Minnetonka, MN 55345 (952)405-6960 Facility (952)456-6466 Fax Read and Initial Each Paragraph
I certify that I have not purposely withheld any information that might adversely affect my chances for employment with Bubbiesitter and Zadies Too®. I attest to the fact that the answers given to me are true and correct to the best of my knowledge and ability. I understand that any omission or false information of material fact on this application or on any document used to secure employment can be grounds for rejection of my application or, if I am employed /contracted by Bubbiesitter and Zadies Too®, terms for my immediate dismissal from Bubbiesitter and Zadies Too®.
INITIAL _____
I understand that if I am employed/contracted at Bubbiesitter and Zadies Too®, my employment may be terminated at any time without prior notice by Bubbiesitter and Zadies Too®.
INITIAL _____
I authorize Bubbiesitter and Zadies Too® to examine my references, record of employment, education record, conduct a background check and any other information to verify the information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Bubbiesitter and Zadies Too, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of, or in any way related to such examination or revelation.
INITIAL _____
Please complete the following information (required by the Minnesota Department of Human Services) to complete your background check for direct care services with Bubbiesitter and Zadies Too®.
Name: ____________________________________________________________________________________________ Address: __________________________________________________________________________________________ City/State/Zip: _____________________________________________________________________________________ Phone Number: ____________________________________________________________________________________ Gender: ___________________________________________________________________________________________ Date of Birth: ______________________________________________________________________________________ Social Security Number: ______________________________________________________________________________ Driver’s License Number: _____________________________________________________________________________ Race: _____________________________________________________________________________________________
