Employment Application

  • Employment Application

  • Personal Information

  • Format: (000) 000-0000.
  • How did you hear about this position?
  • Are you legally entitled to work in the United States?*
  • Are you at least 18 years of age?*

  • In Case of Emergency Notify:        
    Emergency Phone Number:        

  • Position Desired

  • Which position are you applying for:
  • Have you taken the PCA training?
  • Do you have a Certificate?
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  • Do you have a current Driver's License?

  • References

    Please provide THREE references. They can be related, friends, previous employers or patients.

  • Education

  • Employment History

    List below your complete employment history for the last five years, starting with the most recent position first. Or you can upload your resume.
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  • Pre-Employment Application Agreement

  • I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection or dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without cause, and with or without any prior notice.

    I hereby agree that, as a condition of employment by Care4Everyone, I will promptly inform the C4E in writing of any criminal convictions, in any jurisdiction (including all pleas of guilty), other than minor traffic offenses, of which I am convicted after today.

  • VOLUNTARY SELF-IDENTIFICATION INFORMATION

    Care4Everyone is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age, handicap, marital status, source of income, class, physical characteristics, sexual orientation or political beliefs. As an employer, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please complete this Voluntary Self-Identification Information form. This data is for analysis and affirmative action only and submission of this information is voluntary. This data will be kept in a confidential file separate from your Application for Employment.
  • Gender
  • Veteran Status
  • Race/Ethnic Background
  • Disability Status*

  • * According to the American with Disabilities Act, the term “disability” means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of that individual, a record of such an impairment, or being regarded as having such an impairment.

  • Which of the following hours are you willing to work?
  • Which of the following shifts are you willing to work? (Check all that may apply)
  • Which days of the week are you available to work? (Check all that may apply)

  • Pre-Employment Background Check Authorization

  • In the past 10 years, have you lived outside of Minnesota?*
  • Have you changed your name before?*

  • In order for Care4Everyone to process your background check, we will need a copy of 2 forms of identifications. 

  • By signing below, I understand that as part of the employment process, Care4Everyone needs to complete a background check on me.

    • I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to Care4Everyone or its authorized agent(s).
    • I understand that this authorization is to be part of the written and signed employment application.
    • I also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.
    • I further authorize that a photocopy of this authorization may be considered as valid as the original.
    • I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Care4Everyone is contingent upon successful completion of a background check.
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