Employee Application Form Instructions
Complete the information below to apply with Bella Mente. You also need to upload a copy of your Drivers License or State ID, Social Security Card for background study verification, and PCA Certificate. (Click above to take training and receive PCA Cert before filling out app) When your background study clears you will receive an invitation to complete your pre-employment paperwork (W4, I9, Direct Deposit, Etc). When you are approved to work you will receive a Start Work Letter. You are not approved to work and not an employee until you receive a signed Start Work Letter from our office.
Do you have a picture of your ID, SS Card, and PCA Certificate?
You will be required to upload all three items on this form. Please take a picture on your mobile device or have these pictures on your computer before you begin.
Are you applying for a job posted on Facebook or Were you instructed by a Bella Mente Representative to fill out this application? ?
*
Yes
No, I am just applying for work.
Were you instructed by a Bella Mente Representative to fill out this application?
Yes
No, I am just applying for work.
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Thank-you for your interest in employment with Bella Mente
Unfortunately we are not accepting applications at this time. Watch our FB page for job postings.
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Application Date
*
-
Month
-
Day
Year
Date
Job Title
*
PCA
DSW
Other
Application Type
*
New Hire
Rehire
With which gender do you identify?
*
Male
Female
Non Binary
Name
*
First Name
Middle Name
Last Name
Type Full Name
*
First M. Last
Have an Alias/Maiden name, etc? List all names here.
This information used to run background study as required by law. Background studies are required for people in certain health and human services programs, and for people who work in child care settings, if they provide care or have direct contact with people being served.
Please tell us if you have anything that may disqualify you from passing your background.
Form of Identification Type
Drivers License, State ID, etc..
Expiration Date of ID
Drivers License or ID Number
*
State Issued
*
Place of Birth (State)
Are you a US Citizen?
Yes
No
Country of Birth (If not in USA)
Social Security Number
*
All numbers - No dashes 333223333
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2007
2006
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Year
Age
Street Address
*
Street Address
Street Address Line 2 (PO Box, Suite or Apartment Number
City
State / Province
Postal / Zip Code
County (i.e.: St Louis, Itasca, Koochiching, etc...)
*
Please enter the county you reside in
Eye Color
*
Hair Color
*
Height
*
Weight
*
Email Address
*
VERY IMPORTANT THIS IS CORRECT!!!!
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
*
Email
Text
Phone
Have you Lived outside Minnesota in the last five years?
*
No
Yes
If Yes, List Cities & States and length of time (year to year ex.: 2012-2013)
If Yes, List Cities & States and length of time you lived there.
Do you work for another PCA agency?
Type other agencies names
Who will you be the PCA for?
*
Type clients first and last name
What is your Relationship to Client?
Parent, Grand Parent, Sibling, Aunt, Uncle?
Emergency Contact
*
(Name and Phone Number)
Upload an image of your Drivers License.
Browse Files
Drag and drop files here
Choose a file
Take a picture with your camera and then click here to upload
Cancel
of
Alternatively Take a Photo or ID
Upload an image of your Social Security Card.
Browse Files
Drag and drop files here
Choose a file
Take a picture with your camera and then click here to upload
Cancel
of
Alternatively Take a Photo of SS Card
Upload an image of your PCA Training Certificate.
Browse Files
Drag and drop files here
Choose a file
Take a picture with your camera and then click here to upload
Cancel
of
Alternatively Take a Photo of Certificate
Review & Download our Employee Policy and Procedure Handbook
Review & Download the provider agreement summary.
Review & Download Employee Acknowledgements & Agreements
I understand that having direct contact services to people receiving services is a requirement of the position I am being considered for and that having and maintaining a satisfactory record with the Department of Human Services is a condition of my employment with BELLA MENTE. I agree to release BELLA MENTE, its employees, and those who supplied you with the information from any liability for any damage which may result from furnishing the requested information or my failure to be hired for the position for which I am applying. I certify that all elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on this form or any supplements to it will be sufficient grounds for rejection of employment and my discharge after employment.
I authorize BELLA MENTE to submit the above information to DHS to investigate my criminal background as part of the hiring process. I have received a copy of the Privacy Notice, Acceptable Forms of Identification for DHS Background Studies, and Fingerprint and Photo Information for DHS Background Study Subjects.
Acknowledgement
*
I have received and reviewed Bella Mente's policy & procedure handbook, the Provider Agreement Summary, and the Employee Acknowledgements & Agreements. I authorize Bella Mente to submit on my behalf required background and provider enrollment documents with my electronic signature below.
Check if signing electronically.
*
My electronic signature is my legally binding signature.
Enter your initials (MKL or ML, etc..)
*
Sign your name electronically by typing it here (I agree to the PCA enrollment requirements and policies of Bella Mente Inc.
*
Submit Application
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