Employee Intake Form Instructions
Employee Intake Form Instructions
Complete the information below to apply with Best Care. You must also upload a copy of your Drivers License or State ID, Social Security Card for background study verification, and PCA Certificate. When your background study/enrollment is completed you will receive an invitation to complete your pre-employment paperwork (W4, I9, Direct Deposit, etc.). Please have your IDs available to re-submit at that time for I9 verification. 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.
Application Date
*
/
Month
/
Day
Year
Date
Job Title
*
PCA/Support Worker
245D (Waivered Services)
Application type?
*
New Hire
Rehire
With which gender do you identify?
*
Male
Female
Non Binary
Intake Person
*
Intake Person Phone
*
Format: (000) 000-0000.
Intake Person Email
*
example@example.com
Applicant Legal First Name (must match ID)
*
Applicant Legal Full Middle Name
Applicant Legal Last Name (must match ID)
*
Add SR/JR here if applicable
Middle Initial
Other Last Names Used (if any)
*
Drivers License or ID Number
*
State of Issuance
*
Expiration Date
*
-
Month
-
Day
Year
Date
Place of Birth (State)
*
Social Security Number
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Street Address (Residential Address Required for Application - NO PO Boxes)
*
Apt No
City
*
State Abbreviation
*
Zip Code
*
County
*
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Are you 18 years old or older?
*
Yes
No* *May affiliate with only one agency
If you are under 18 years old, have you worked for another agency?
Yes
No
Are you a previous employee?
*
Yes
No
Have you Lived outside Minnesota in the last five years? Inaccurate information may delay the background study
*
No
Yes
If Yes where?
From Year
To Year
Current Name on MN IT'S
Do you work for another agency?
Do you receive services, or have you received services in the past 12 months?
Yes
No
Who will you work for? Please list the client's name if you know.
*
What is your Relationship to Client?
Notes
Emergency Contact (Name and Phone Number)
UMPI (if requesting reinstatement)
PCA CERTIFICATE DATE
-
Month
-
Day
Year
Date
PCA CERTIFICATION NUMBER (If Known)
APPLICATION NUMBER
BGS NUMBER
AGENCY PERSONNEL COMPLETING FORM
*
Upload an image of the front and back of your Drivers License
*
Browse Files
Drag and drop files here
Choose a file
pdf, jpg, jpeg, png, or gif only
Cancel
of
Upload an image of the front and back of your Social Security Card or a certified copy of birth certificate.
*
Browse Files
Drag and drop files here
Choose a file
pdf, jpg, jpeg, png, or gif only
Cancel
of
Upload an image of your PCA/CFSS Certificate. Is a requirement to work as a PCA/Support Worker
Browse Files
Drag and drop files here
Choose a file
pdf, jpg, jpeg, png, or gif only
Cancel
of
Review our Policy and Procedure Manual
Review the provider agreement summary.
Privacy Notice
Acknowlegement.
*
I have received and reviewed the Best Care policy procedure manual, Provider Agreement Summary and Privacy Notice.
Medical reimbursement plan.
*
I do NOT wish to participate in the tax-free, employer sponsored Minimum Essential Coverage Plan.
I want to participate in the Minimum Essential Coverage Plan
Check if signing electronically
*
My electronic signature is my legally binding signature.
Enter your initials (AEB or AB etc.)
*
If you have a middle name you should have 3 characters here
Prefered Method of Contact
Mail
Email
Phone
Type a question
Type a question
Type a question
Preview PDF
Submit
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