Inspired By You is an equal opportunity employer and encourage diversity in employment. Inspired By You makes all hiring decisions without regard to an applicant’s race, religion, sex, age, national origin, sexual orientation, disability or other protected classification under federal, state or local equal opportunity laws.
Please fill out all required fields before proceeding forward.
Please fill out all required fields before proceeding forward.
Please fill out all required fields before proceeding forward.
Please read the following document carefully before proceeding forward.
Please fill out all required fields before proceeding forward.
APPLICANT INFORMATION
First Name
Middle Name
Last Name
Street Address
City
State
Zip
Are you at least 18 years of age?
Home Phone
Work Phone
Are you authorized to work in the United States on an unrestricted basis?
Can you speak any language other than English (including ASL)?
Language
Have you worked for Inspired By You before?
If yes, specify the position and dates
EMPLOYMENT DESIRED
Position
Branch Location
Wages Desired
Date Available
Times [Available [Monday]
Times Available [Tuesday]
Times Available [Wednesday]
Times Available [Thursday]
Times Available [Friday]
Times Available [Saturday]
Times Available [Sunday]
How did you learn of this opening?
What cities/locations are you willing to work in?
You would prefer to work with clients who are
Some employment sites are home based. Are you willing to work in a home with pets?
Are you willing to work in smoking environment?
Are you currently a recipient of PCA services?
QUALIFICATIONS
Do you possess a valid driver license?
Have you received three or more traffic violations in the last 3 years?
Has your driver's license been suspended or revoked in the last 3 years?
Please explain any YES answers to questions 2 or 3 below:
EDUCATION
HIGH SCHOOL/GED EDUCATION
High School / GED completed?
Degree
Name of School
City, State
Major
TECHNICAL/VOCATIONAL EDUCATION
Technical/Vocational completed?
Degree
Name of School
City, State
Major
COLLEGE/UNIVERSITY EDUCATION
College/University completed?
Degree
Name of School
City, State
Major
OTHERS
Other Education Degree?
Degree
Name of School
City, State
Major
Nurse License, if applicable
SPECIALIZED TRAINING, CERTIFICATION OR EXPERIENCE
First Aid
Additional Comment
CPR
Additional Comment
Positioning/Transferring/Lifting
Additional Comment
Communication Techniques
Additional Comment
Home Health Aide, Homemaker, Personal Care
Additional Comment
Other
Additional Comment
FOR MINNESOTA ONLY
Do you have a current Individual PCA Provider number?
If yes, what is the number?
WORK HISTORY
Inspired By You and its affiliates bill Medicare for some of the services rendered. We must inform Medicare of any employee who has been employed by a Medicare Fiscal Intermediary during the past twelve months. If a Medicare Fiscal Intermediary has employed you in the past twelve months, please indicate the employer and the dates of employment below.
If you are currently employed, may we contact your employer?
For the below fields, please begin with current or most recent employer or position with employer:
EMPLOYER 1
Employer's Name
Address
Supervisor
Phone
Starting Date
Ending Date
Ending Wage
Position
Description of Job
Reason for Leaving
EMPLOYER 2
Employer's Name
Address
Supervisor
Phone
Starting Date
Ending Date
Ending Wage
Position
Description of Job
Reason for Leaving
EMPLOYER 3
Employer's Name
Address
Supervisor
Phone
Starting Date
Ending Date
Ending Wage
Position
Description of Job
Reason for Leaving
REFERENCES
Inspired By You requires that all applicants submit two references, which must include: current or former employers, supervisors, teachers or others qualified to objectively evaluate your ability to work in the position for which you have applied. Please list the reference information indicated below. Inspired By You will be contacting each reference listed.
Reference 1
Name
Relationship to Applicant
Daytime Phone #
Evening Phone #
Reference 2
Name
Relationship to Applicant
Daytime Phone #
Evening Phone #
(3) Name
Relationship to Applicant
Daytime Phone #
Evening Phone #
THANK YOU FOR YOUR INTEREST IN INSPIRED BY YOU
We at Inspired By You are pleased you are interested in becoming a member of our Company. We are proud of our excellent reputation and the services we provide. We value diversity and want your work experience to be enjoyable. To help ensure a safe work environment and excellent services we carefully screen the background of all applicants. This screening may include an oral interview, as well as an investigation of your work history, criminal conduct, driving record, application information, and reference check. APPLICANT DECLARATION OF UNDERSTANDING
- I understand that Inspired By You may conduct an investigation of the information I have noted on this application and, as part of that investigation, may contact prior employers and references, among others.
- I authorize Inspired By You to conduct this investigation and I release from all liability and hold harmless any person giving or receiving information about me relative to this investigation.
- I understand that any falsification, misrepresentation, or omission of information discovered as a result of this investigation may prevent me being hired or if hired, may subject me to the immediate termination of my employment with Inspired By You.
- I understand that Inspired By You requires an applicant to disclose criminal history if selected for an interview, or if a conditional offer of employment has been made, the decision may be subject to a criminal background check.
- I understand that this application process does not create an employment contract.
- I understand all employment at Inspired By You is "at-will." This means, if Inspired By You employs me, my employment is not for a specified or definite period of time and that I may resign or be discharged from my position at any time, for any reason, with or without cause or prior notice.
- I understand that the "at-will" policy listed above cannot be changed or amended without a formal written employment agreement signed by me and by a member of the Board of Directors of Inspired By You.
- I declare that I have never committed nor been charged or convicted of any act of abuse, neglect, exploitation or fraud in relationship to a dependent/vulnerable child or adult, within the past 10 years.
- I declare that I have never knowingly violated any applicable rules or laws in any previous employment in a residential healthcare or similarly related employment.
- I declare that the Office of Inspector General from participating in the Medicaid or Medicare programs has never excluded me.
Inspired By You supports the principles of equal employment opportunity. Inspired By You is dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, national origin, the presence of mental, physical, or sensory disability, sexual orientation, or any other basis prohibited by federal, state, or local laws.
By checking this box, I agree that I have read and understand the declarations of understanding listed above and I assert that all information given in this application is true.
ATTACHMENT
If desired, you may upload two of your personal documents that identifies you.
Upload Resume
Max. size: 256.0 MB
Upload File 1
Max. size: 256.0 MB
