Employment Applicaion

Personal Information

Contact Name
Street Address
Mailing Address
Date of Birth
Military Service?
Are you authorized to work in the United States of America?
Have You been Convicted of a Felony?

Emergency Contacts

Primary

Alternate

Employee Intake: Informed Consent

Authorization and Release Form

I hereby give CareTeam Home the right to conduct a thorough investigation of my past employment, education, and related activities. I release CareTeam Home and/or its authorized agents from all liability in obtaining information from any government agencies, social service agencies, or law enforcement agencies. I also authorize these entities to provide any and all information concerning my background and release them from any liability arising from the disclosure of such information.

CareTeam Home does not perform credit checks; however, as part of the hiring process, a criminal background check is required. I understand that I must successfully pass a criminal background check conducted by the Minnesota Department of Human Services (MN DHS). If I am disqualified for any reason based on the results of this background check, I understand that CareTeam Home cannot proceed with my employment.

If my application for employment is approved, I understand that CareTeam Home may conduct additional investigations through a consumer reporting agency to evaluate my eligibility for promotion, reassignment, retention, and to comply with operating license, liability insurance, or state/federal requirements. This may include initial and annual criminal conviction checks, as well as investigations resulting from alleged employment misconduct, negligence, or incidents involving my employment with CareTeam Home, its clients, consumers, or agents. This authorization remains valid throughout my employment.

I acknowledge that the disclosure of a criminal record will not automatically disqualify me from employment consideration. Each case will be evaluated individually in accordance with MN DHS rules and regulations. I further understand that any false information, misrepresentation, or deliberate omission in my application or any other employment-related document, or any act of willful misconduct, shall be sufficient grounds for denial or termination of employment.

I hereby release any individual or institution, including their officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of any kind that may result from complying with this authorization or releasing such information.

I understand that a consumer and/or investigative consumer report may be obtained for employment purposes.

MN Residence only: I WOULD like a copy of any consumer report regarding me.
I am willing that a photo copy or electronic copy of this consent form be accepted with the same authority as the original.
Date of Birth
Clear Signature

Employee Intake: Net Study

US Citizen?
Have you had any previous documented Name or Alias?
In the last 5 years, have you lived in a state other than Minnesota?
Address
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