PCA Application Survey

1. First Name, Middle Initial & Last Name

First Name, Middle Initial & Last Name

2. Email Address (*extremely important*) & Phone Number:

Email Address (*extremely important*) & Phone Number:

3. Where do you currently reside (street, city, state, zip)?

Where do you currently reside (street, city, state, zip)?

4. Education (please list high school with graduation year, as well as any post-secondary education with dates and degree/certification):

Education (please list high school with graduation year, as well as any post-secondary education with dates and degree/certification):

5. Employment History (please list your three most recent jobs starting with the most recent, with company name, company city & state, job title, dates of employment, supervisor name, phone number and reason for leaving)

Employment History (please list your three most recent jobs starting with the most recent, with company name, company city & state, job title, dates of employment, supervisor name, phone number and reason for leaving)

6. References (please list THREE three PERSONAL, non-family, references complete with first & last name, phone number, email address, and how you know them. An EMAIL ADDRESS is IMPORTANT, please provide when possible)

References (please list THREE three PERSONAL, non-family, references complete with first & last name, phone number, email address, and how you know them. An EMAIL ADDRESS is IMPORTANT, please provide when possible)

7. I... (check all that apply)

I... (check all that apply) Am a female Required Am at least 18-years-old Required Am at least 21-years-old Am a non-smoker from a non-smoking environment Required Have a valid driver's license and my own vehicle to get myself to-and-from work Required	Have a perfectly clean background check (if no, please explain) Already have a Personal Care Attendant certificate from the MN DHS (not required) Am not allergic to dogs and am comfortable around them Required Do not have a history of back problems Speak and understand English very clearly Required	Have regular access to email and text messaging Required Have access to a webcam for a preliminary interview (not required, but is a bonus) Am seeking short-term employment (6-9 months) Am seeking long-term employment (over 9 months)
Other (please specify)

8. I can comfortably, easily, independently lift...

I can comfortably, easily, independently lift... 0-25lbs 26-50lbs 51-70lbs	71-80lbs 81-90lbs 91-100lbs	101-110lbs 111-120lbs 121lbs or more
Other (please specify)

9. I'm generally available to work the following days and times until at least mid-May (please list your entire availability, including hours beyond what hours you're interested in):

I'm generally available to work the following days and times until at least mid-May (please list your entire availability, including hours beyond what hours you're interested in): Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

10. What else can you tell me about you (i.e. stuff beyond your experience and credentials; hobbies, interests, family, fun facts... really show me who you are and make me want to meet you!)

What else can you tell me about you (i.e. stuff beyond your experience and credentials; hobbies, interests, family, fun facts... really show me who you are and make me want to meet you!)

I... (check all that apply) Am a female Required Am at least 18-years-old Required Am at least 21-years-old Am a non-smoker from a non-smoking environment Required Have a valid driver's license and my own vehicle to get myself to-and-from work Required	Have a perfectly clean background check (if no, please explain) Already have a Personal Care Attendant certificate from the MN DHS (not required) Am not allergic to dogs and am comfortable around them Required Do not have a history of back problems Speak and understand English very clearly Required	Have regular access to email and text messaging Required Have access to a webcam for a preliminary interview (not required, but is a bonus) Am seeking short-term employment (6-9 months) Am seeking long-term employment (over 9 months)
Other (please specify)