218-281-3506
Independence Plus, Inc. - Employment

Employment Application

Please make sure you fill out all the form blanks, failure to do so will submit a incomplete application.

Incomplete applications will NOT be considered for employment. Please allow two weeks for processing.

Every Personal Care attendant and Homemaker must take the Department of Human Services PCA training. To do this you must go to This Link and register then follow the directions to complete the test.

Our Company Provides a variety of Benefits:

  • Health Insurance BCBS (Employees with 30 or more hours/wk)
  • Life Insurance
  • Retirement Options (Ozark National Life Insurance & NIS Financial Services)

For more information or questions, please call our Payroll staff (Mickey Kyler) at (218)-281-3506

Independence Plus Inc. Online Application

The Application Fee is ONLY required for those who are being recruited for specific recipient(s).
Please include with Application Fee ($20):

      Copy of Identification
      Copy of SS card

Background Studies can not be initated until such Fee/Copies have been submitted and recieved.
Contact the Office with any questions (218)-281-3506.

Position:
 PCA Homemaker Office Staff Qualified Professional IHFS Provider Personal Support Other

*Last Name:

*First Name:

*Middle Name:

*Social Security Number:

*Address:

*City:

*State:

*Postal Code:

*Telephone:

*Cell Phone:

*Emergency Contact:

*Phone:

*Cell Phone:

Education

*High School Grade Completed:

*College Years Completed:

*High School Name:

*Address:

*City:

*State:

*Postal Code:

*Phone:

*Country:

*College Name:

*Address:

*City:

*State:

*Postal Code:

*Phone:

*Country:

Describe any other education & licenses:

Describe any other skills or qualifications that might help you at this job:

Are you applying for a position with a specified client?
 Yes No

If yes, who?

Can you read, write and speak English?
 Yes No

Other languages?

Are you legally authorized to work in the United States?
 Yes No

Do you have a CNA license?
 Yes No

License #

Do you have a driver's license?
 Yes No

License #

Do you have auto insurance?
 Yes No

Company Name

Are you at least 18 years old?
 Yes No

Are you currently using Personal Care Services?
 Yes No

Do you understand that all employees must work weekends?
 Yes No

Employment History

Employer

Address

Phone

From (MM/YYYY)

To (MM/YYYY)

Position

Supervisor/Manager

Describe the work you did

Reason for leaving

Employer

Address

Phone

From (MM/YYYY)

To (MM/YYYY)

Position

Supervisor/Manager

Describe the work you did

Reason for leaving

Employer

Address

Phone

From (MM/YYYY)

To (MM/YYYY)

Position

Supervisor/Manager

Describe the work you did

Reason for leaving

May we contact the employers above?
 Yes No

If not, please indicate those you do not wish us to contact.

References (Not Relatives)

Name

Title

Phone

Email Address

Name

Title

Phone

Email Address

Name

Title

Phone

Email Address

Availability

List hours that you would be available for work or hours you could not work. Please specify

Under the Minnesota Data Privacy Act, you have the right to know how the information you provide on your application will be used. By signing this you authorize us to use this information for determining job qualifications. Independence Plus is an equal opportunity employer.

Applicant's signature

Date Signed


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Contact

27885 170th Ave. SW
Crookston, MN 56716-9444
Ph: (218) 281-3506
Fax: (218)281-3015
© 2019 Independence Plus, Inc.
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