H&H Employee Application

Are you applying for a job posted on Facebook?*

YesNo

Were you instructed by a Heart & Hara Representative to fill out this application?*

YesNo, I am just applying for work.

Email

example@example.com

Application Date*

Date

Job Title*

CaregiverOther

Application Type*

New HireRehire

With which gender do you identify?

MaleFemaleNon Binary

Name*

First NameMiddle NameLast Name

Type Full Name*

First M. Last

Alias/Maiden name, former married names, etc

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)*

Social Security Number*

Birth Date*

MonthDayYear

Age

Street Address *

Street Address

Street Address Line 2 (PO Box, Suite or Apartment Number

CityState / Province

Postal / Zip Code

County (i.e.: Lake, St Louis, Koochiching, etc...)*

Please enter the county you reside in

Eye Color*

Hair Color*

Height*

Weight*

Are you a US Citizen?

YESNO

What is your nationality (for background purposes)

Email Address*

VERY IMPORTANT THIS IS CORRECT!!!!

Phone Number*

Please enter a valid phone number.

Preferred Method of Contact*

EmailTextPhone

Have you Lived outside Minnesota in the last five years?*

NoYes

If Yes, List Cities & States and length of time (year to year ex.: 2012-2013)

If Yes, List Cities & States and list years you lived there.

ex: Fargo, ND 2020 to 2021

Do you work for another PCA agency?

Type other agencies names

Who will you be Caregiver 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.

Take a picture with your camera and then click here to upload

Alternatively Take a Photo or ID

Upload an image of your Social Security Card.

Take a picture with your camera and then click here to upload

Alternatively Take a Photo of SS Card

Upload an image of your PCA Training Certificate.

Take a picture with your camera and then click here to upload

Alternatively Take a Photo of Certificate

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 Heart & Hara Home Care. I agree to release Heart & Hara Home Care, 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 Heart & Hara Home Care 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 Heart & Hara's policy & procedure handbook, the Provider Agreement Summary, and the Employee Acknowledgements & Agreements. I authorize Heart & Hara Home Care 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 enrollment requirements and policies of Heart & Hara Home Care*

Employee Application Form Instructions

Do you have a picture of your ID, SS Card, and PCA CFSS Training Certificate?

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.