Personal Care Attendant Application for Employment

1 Access North Center for Independent Living of Northeastern Minnesota (CILNM). Main Office Branch Office 1309 E 40th Street, Hibbing, MN 55746 118 E Superior St, Duluth, MN 55802. Phone: 218-262-6675 or 800-390-3681 Phone: 218-625-1400 or 888-625-1401. Fax: 218-262-6677 Fax: 218-625-1401. Personal care Attendant Application for Employment I understand that Access North CILNM operates a PCA Choice Program and this program allows individuals who receive PCA services or their responsible party control and choice in choosing, hiring, training, and supervising their PCA's.

2 My signature on the back of this Application indicates that I. understand that this Application for Employment will be forwarded to individuals who receive PCA. services or their responsible party for their review and consideration in hiring me. Personal DATA Please print NAME First Middle Last Phone Number ( ) - Address City State Zip Do you have a valid driver's license? Yes No Do you have access to reliable transportation? Yes No Do you have automobile liability insurance as required by Minnesota state law? Yes No Are you legally eligible to work in the United States?

3 Yes No Have you ever been convicted of a felony? Yes No If yes, please explain and list location. Referral Source: CILNM website School posting Craigslist Walk-in Other How far are you willing to travel from home to work? Availability: Full-time Part-time Temporary How many hours do you want to work a week? Date available to start work? What days and times are you available to work? Sunday Monday Tuesday Wednesday Thursday Friday Saturday EDUCATION AND TRAINING. School Name of School, City and State Graduated/GED? Major Course of Study High School College Other Training Have you completed the required Individual PCA Training on the DHS website?

4 Yes No Please list any other licenses or certificates you hold that might be pertinent to this position. Please list any special skills or job-related information you feel is necessary to describe your full qualifications. General Documents>PCA Choice PCA Hire Packets>PCA Application for Employment 06/15/2013. Employment History, beginning with most current Name of Employer Phone Number Position or Title Start Date End Date Name of Immediate Supervisor May we contact? Yes No Reason for Leaving Name of Employer Phone Number Position or Title Start Date End Date Name of Immediate Supervisor May we contact?

5 Yes No Reason for Leaving Name of Employer Phone Number Position or Title Start Date End Date Name of Immediate Supervisor May we contact? Yes No Reason for Leaving Employment Reference Information Name Phone Number Company City / State Relationship to you May we contact? Yes No Name Phone Number Company City / State Relationship to you May we contact? Yes No Name Phone Number Company City / State Relationship to you May we contact? Yes No I declare that all information provided is true and complete. My signature on this Application provides permission to contact present/previous employers and references, unless otherwise noted, and to investigate any statements contained in this Application .

6 I understand that any misrepresentation or omission of material fact on this Application form or in the course of the Application process is cause for termination of Employment . Signature Date General Documents>PCA Choice PCA Hire Packets>PCA Application for Employment 06/15/2013.