Employee Intake Form Instructions
Employee Intake Form Instructions
Complete the information below to apply with Best Care. You also need to upload a copy of your Drivers License or State ID, Social Security Card for background study verification, and PCA Certificate. 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.
Application Date
*
/
Month
/
Day
Year
Date
Job Title
*
PCA
245D (Waivered Services)
Application type?
*
New Hire
Rehire
With which gender do you identify?
*
Male
Female
Non Binary
Intake Person
*
Intake Person Phone
*
Intake Person Email
*
example@example.com
Applicant First Name
*
Applicant Middle Name
*
Applicant Last Name
*
Add SR/JR here if applicable
Middle Initial
*
Alias/Maiden name, etc
*
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
*
Are you 18 years old or older?
*
Yes
No* *May affiliate with only one agency
Are you a citizen of the United States?
*
Yes
No
Street Address (Residential Address Required for Application - NO PO Boxes)
*
Apt No
City
*
State Abbreviation
*
Zip Code
*
County
*
Email
*
example@example.com
Phone Number
*
Would you like to sign up for direct deposit?
Yes (complete below)
No paper check
Bank Name
Routing Number
Account Number
Acknowledgement
I have received the instructions on how to fill out the State & Ferderal W4
State W-4 Instructions
Federal W-4 Instructions
Marital Status for State taxes?
Single, married but legally separated or spouse is a nonresident alien
Married
Married, but withhold at a higher single rate
Number of Minnesota Witholding Allowances?
For instructions view PDF form above.
Are you exempt from Minnesota Witholding?
Yes
No
What is the exemption reason you are claiming?
I meet all the requirments for Federal and State Exemption.
Even though I did not claim exemption from Federal Witholdings I am exempt from State witholding.
My spouse is a military service member stationed in Minnesota; my residence is in aother state; and I am in Minnesota only to be with my spouse.
I am an American Indian that resides and works on a reservation.
I am a member of the National Gaurd and claim exempt on military pay.
I receive a military pension.
Marital status for Federal taxes
Single or Married filing separately
Married filing jointly or qualifying widow(er)
Head of household
Step 2: Multiple Jobs or Spouse Works (c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld.
Federal Deduction Amount?
For instructions view PDF forms above
Other Additional Federal Witholding Amount?
Are you a previous employee?
*
Yes
No
Have you Lived outside Minnesota in the last five years?
*
No
Yes
If Yes where?
From Year
To Year
Current Name on MN IT'S
Do you work for another PCA agency?
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
Previously enrolled with MCO
Yes
No
Group Affiliation
Yes
No
AGENCY PERSONNEL COMPLETING FORM
*
Upload an image 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 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 Certificate. Is a requirement to work as a PCA
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.
Acknowlegement.
*
I have received and reviewed the Best Care policy and procedure manual and provider Agreement Summary.
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
Type a question
Preview PDF
Submit
Should be Empty: