main application 1

8/7/2019 main application 1

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EMPLOYMENT APPLICATION

Mainsl Services, Inc. is an Equal Opportunity & Affirmative Action employer. All qualified applicants will receive considerationwithout regard to race, color, creed, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation,marital status, gender identity, genetic characteristics, military status or status with regard to public assistance, or other protected

characteristics as defined by law.

Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative ofthe Human Resources Department.

PERSONAL INFORMATIONLast Name First Name Middle Initial Date of Application

Address City, State Zip

Home Telephone Number Alternate Telephone Number E-Mail Address

If hired, can you present proof of legal authorization to work in the United States? YES NOIf hired, you will be required to provide documentation verifying citizenship or eligibility to work in the United StatesAre you under the age of 18? YES NO

Do you have a valid drivers license? YES NO If yes, valid in what State: __________________________

Do you have valid automobile insurance? YES NO

Have you ever been convicted of a felony? YES NOConviction of a felony does not automatically disqualify you from employment.

Date of conviction:

If yes, please explain:

Have you ever applied for employment with Mainsl Services? YES NO

Have you previously been employed by Mainsl Services? YES NO

If yes, under what name? Dates of employment:

Position(s) held:

AVAILABILITYPosition applying for Requisition Number Salary Requirements

Number of hours desired FT PT (# OF HOURS PER 2 WEEKS _________________) CASUAL/ON-CALL

Shift desired Day Evening Overnight Weekdays Weekends All Shifts Other

Date available to start work: ___________________________

EDUCATIONHigh School Did you graduate?

YES NODegree Earned

College or University Did you graduate?YES NO

Degree Earned

Graduate School Did you graduate?YES NO

Degree Earned

List any other special skills, activities, training, or experience that you believe would be of value to Mainsl Services and/or the job(s) youare applying for:

SUNDAY ARO TITILAYO 07/05/2010

965 APT.8 AVON STRRET ST PAUL MN55103

651 -207-9146 651-207-9146 [email protected]

Minnesota

PCA

PCA 37562 7.535

07/06/2010

ORIWU HIGH SCHOOL WASC

FIRST AID,LIFTING,HAVING AN EXPERIENCE IN WORKING WITH HIGHLY VUNERABLE INDIVIDUAL.

COOKING, CLEANING.

SUBMIT PRINT

SUNDAY ARO 03/2010


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PROFESSIONAL LICENSE/CERTIFICATIONSLicense/Certification Name License/Certification Number Expiration Date

Are there any restrictions on your license? YES NO If yes, explain:

Are you CPR certified? YES NO If Yes, expiration date Are you First Aid certified? YES NO

REFERENCESPLEASE LIST 3 PROFESSIONAL WORK REFERENCES. DO NOT INCLUDE FRIENDS OR RELATIVES.

Name Relationship Phone number and e-mail address



EMPLOYMENT HISTORY

Starting with your Current or Last Employer, PLEASE LIST ALL JOBS YOU HAVE HADfor the past seven (7) years. It is optional toprovide dates of employment for jobs held more than seven (7) years ago. Do not omit work experience just because it may beunrelated to the job for which you are applying. IT IS REQUIRED THIS SECTION BE COMPLETE EVEN IF YOU ARE PROVIDINGA RESUME.Current/Last employer name

Address City, State Zip code

May we contact? YES NO Person to contact Phone number

Your supervisors name and phone number Reason for leaving

Employed from (month,year)

Employed to (month, year) FT PT Casual/On-Call Job title

Description of job duties

Salary Per Hour Year Bonus or other compensation

Employer name








Employer name








PLEASE EXPLAIN ANY GAPS IN EMPLOYMENT

STACY ROE CDO MANAGER 763 416 9146

JUDY ALBERTA CLIENT 952 936 9642

FOLAKE ADELAKUN NURSE 651 238 3975

MAINLS SERVICES,INC

7000 78TH AVENUE NORTH BROOKLYN PARK, 55445

STACY ROE 763 416 9146

STACY ROE 763 416 9146 DUE TO DEATH OF THE CONSUMER.

MARCH PERSONAL CARE ATTENDANT

TRANSFERING THE CLIENT FROM THE WEEL CHAIR TO THE BATHROOM,CLEANING,COOKING,ERRANDS,AND

OTHERS

7.5

PUNCH NEWS PAPERS

IKEJA, LAGOS, N IGERIA 234

AYANKUNBI 234 8120707999 RELOCATION

JANUARY 2005 CIRCULATION EXECUTIVE,MARKETING OFFICER

INVOLVING IN DISTRIBUTION OF THE NEWSPAPERS AND MARKETING OF THE PRODUCTS.

52,000

WAVELINK GLOBAL IN VESTMENT LTD

ABUJA FCT ABUJA 09

MARY TALOR 0802443563

MARY TALOR 0802443563 RELOCATION

MARCH,2009 BUSINESS MANAGER

FACILITATING THE BUSINESS TANSACTIONS,MEETING THE CUSTOMERS SEE TO THE DAY TO DAY

ACTIVITIES OF THE ORGANISATION

58,000

2001 ,FEBUARY

2006,APRIL

2010


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STATEMENT, AUTHORIZATION AND RELEASEPLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INITIAL EACH PARAGRAPH

(Contact a member of Human Resources with any questions)

_____I certify that all information contained in this application and other information I have provided is true, correct and complete. Iunderstand that falsification or omission of information provided by me may disqualify me from consideration for employmentor result in immediate dismissal if discovered at a later date.

_____I understand that nothing contained in the application or conveyed to me during any interview which may be granted is

intended to create an employment contract, implied or explicit, between me and Mainsl Services Inc. I understand and agreethat if I am offered and accept employment with Mainsl Services, my employment is for no definite period and may beterminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or MainslServices. I understand that no supervisor or representative of Mainsl is authorized to make any assurances to the contraryand that no implied oral or written agreement are valid unless they are in writing and signed by the Chief Executive Officer orVice President of Human Resources.

_____I authorize any person or organization referenced in this application to give representatives of Mainsl Services any and allInformation concerning my previous employment, education or any other information they might have, personal or otherwise,with regard to any of the subjects covered by this application and release all such parties from all liability for any damage thatmay result from furnishing such information to Mainsl Services, Inc. I authorize Mainsl Services, Inc. and/or theirrepresentatives to request and receive such information. Mainsl Services may also investigate my driving record and criminalrecord. I understand my application may be released to social services or other regulatory agencies for the purpose offulfilling Mainsl Services licensing requirement.

_____I understand that any offer of employment will be contingent upon successful completion and clearance of: proof of legalauthorization to work in the United States, health screening report, criminal and/or other licensing background clearance,reference checks, clean motor vehicle report and valid motor vehicle insurance, if applicable. In accordance with the FairCredit Reporting Act, the California Consumer Investigative and Credit Reporting Agencies, or Minnesota Statute, Acts and inaccordance with the Federal Trade Commission, I understand that I have the right to request a complete and accuratedisclosure of the nature and scope of the investigation requested. I am entitled to know if employment is denied because ofinformation obtained by Mainsl Services from a Reporting Agency.

_____If employed by Mainsl Services, I agree to follow all rules, policies, and procedures, and that they may be changed at any timeat the discretion of Mainsl Services, Inc. with or without prior notice to me.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT.I certify that I have read, fully understand and accept all term of the Statement,Authorization and Release

SIGNATURE DATE07/05/2010SUNDAY ARO

.


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EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

Mainsl Services, Inc. is an Equal Opportunity Employer. In order to improve our recruiting programs and comply

with the Federal and State governments information requests, we must ask the questions below.

You are not required to provide the information. However, if you choose to provide the information, then it will bekept separate from youre application and employee file. If you choose not to, then your decision will not affect youremployment opportunity with Mains'l Services, Inc.

Thank you for your help and cooperation!

Gender (please check only one)

FEMALE

MALE

DO NOT WISH TO DISCLOSERace/Ethnic Group (please check only one):

The Federal Government uses the following definitions of race/ethnic groups:WHITE (not of Hispanic origin): a person having origins in any of the original peoples of Europe, North Africa, the Middle East.

BLACK or AFRICAN AMERICAN (not of Hispanic Origin): a person having origins in any of the Black Africanracial groups.

HISPANIC OR LATINO: a person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanculture of origin, regardless of race.

ASIAN: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indiansubcontinent.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: a person having origins in any of the original peoples oHawaii, Guam, Samoa, or other Pacific Islands.

AMERICAN INDIAN OR ALASKA NATIVE: all persons having origins in any of the original peoples of NorthAmerica and who identifiable tribal affiliations through membership and participation or community recognitionTWO OR MORE RACES

DO NOT WISH TO DISCLOSE

Physical Disability (please check only one)Do you have a mental or physical disability? Disability is defined as having a physical, sensory, or mentalimpairment (or condition) that materially (or significantly) limits one or more major life activities; having a recordsuch impairment; or being regarded as having such an impairment.

YES

NO

DO NOT WISH TO DISCLOSE

ATTENTION HUMAN RESOURCES:Please detach the EEO Form from the employment application and file it in the EEO Form File. Do not file EEOForms in the personnel file.


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1

Mainsl Services IncProgram Specialist Assessment

To the Applicant: The following assessments will demonstrate your basic knowledge of skillsnecessary to perform specific tasks related to the Program Specialist position.

Name: Date:

BEHAVIORAL SCENARIO:

Read the following scenario. In four or more sentences, describe how you would

address the situation. What problem solving techniques might you use?

Lily uses a wheelchair and is mostly nonverbal; she does understand and makessome sound for communication. She enjoys watching Walt Disney movies. The twoof you are watching TV. The program you are watching is a talk show that you wantto watch. Lily starts to scream.

STACY ROE 07/05/2010

I WILL ALLOW LILY TO WATCH HER PROGRAMME, OR WALT DISNEY MOVIES.

BECAUSE CONSUMER/CLIENT INTEREST COME FIRST.


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2

Mainsl Services Inc.Program Specialist Assessment

FINANCIAL EXERCISE

Showing your work below, calculate the answers to the following problems.

1. Ken has $25.00 to spend on weekend activities. On Friday night, May 7, 2004he goes to the movies and spends $4.50 for his ticket and $4.00 for popcorn andpop. On Saturday, May 8th, Ken goes shopping at Target and buys a T-shirt anda pair of shorts for $12.00. Sunday afternoon, May 9

th, Ken stops at Dairy

Queen and buys an ice cream cone for $1.25. How much money does Ken haveleft at the end of the weekend?

Complete Kens Cash Record Sheet (attached) recording the weekend

expenses and ending balance.

2. On May 1, 2004, staff takes $10.00 in petty cash when they take a consumer toeat at McDonalds. Staff spends $4.39 on a meal. How much petty cash is leftfrom the purchase?

Complete the Petty Cash Ledger (attached), recording the staff meal.


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MAINS'L SERVICES, INC.

CASH RECORD SHEET

NAME:

MONTH/YEAR:

CASH

RECEIPT TRANSACTION STAFF BEGINNING BALANCE

DATE NUMBER DESCRIPTION CHECK # INITIALS DEPOSIT PAYMENT BALANCE

TOTALS

CASH BALANCE CARRIED FORWARD

*Bank withdrawal must also be listed as cash deposit.

25.00

07 01 MOVIES TICKET 01 S.A 25 4.50 20.5007 02 POPCON/POP 02 S.A 4.00 16.50

08 03 T.SHIRT,A PAIR OF SHORT 03 S.A 12.OO 4.50

09 04 ICE CREAM CONE 04 S.A 1.25 3.25

25.00 21.75 3.25

3.25

KEN"S

MAY,2004


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MAINS'L SERVICES, INC.PETTY CASH LEDGER SLS: Bank Balance $

Month/Year: Beginning Cash BalancCHECK ONE

STAFF CASH EXPENSE/ DATE ECEIPT Groc Prog Supp SITE OF PURCHASE ITEM PURCHASED INITIALS DEPOSIT ITHDRAWA

Ending Cash Balance$Total Cash Expenditures $_________Total Bank Expenditures $_________ Ending Bank Balance

TOTAL EXPENDITURES $__________P. M. Signature (

MAY,1ST

01 01 MACDONALD BURGER S.A 10.00 4.39

4.39

5

4.39


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3

Mainsl Services IncProgram Specialist Assessment

DOCUMENTATION

Instructions: Using the following information, please complete the attached Incident

Report for Jim Brown. All incidents with injury must be reported to the

administrative pager. (the current administrative person is Jane Smith)

The Incident Report must also include first aid that is administrated.

Jim Brown was walking into the house after getting off his work van at 3:30 pm on May29, 2004. He lives at 4900 Hemlock Lane in Maple Grove. He tripped on a rock andfell to the ground. He got up on his own but his right knee was bleeding and had an openscratch 2 inches long. Medical attention was not required.


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JIM BROWN

MAY,29, 04 3.30

4900,HEMLOCK LANE MAPPLE GROVE

JIM BROWN WAS WALKING INTO THE HOUSE AFTER GETTING OFF FROM HIS

WORK VAN.HE TRIPPED ON A ROCK AND FELL ON THE GROUND. HE GOT UP

ON HIS OWN BUT HIS RIGHT KNEE WAS BLEEDING AND HAD AN OPEN

SCRATCH 2 INCHES LONG.IMMEDIATLY,I TOOK HIM INTO HIS HOUSE AND

WATCH THE INJURIES WITH ALCOHOL WIPE AND APPLY FIRST AID BAND AID.


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SOMEONE WORKING ON THE STREET,MISSES HE OR HER STEP AND RESULTED

TO HAVING BRUISES ON THE SKIN OR ANY PART OF THE BODY PEEL OFF.

(click on the area(s)of injury on the diagrams


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4

Mainsl Services Inc

Program Specialist Assessment

MALTREATMENT:

Do the following scenarios reflect incidents of maltreatment, (abuse, neglect, or

financial exploitation)? You may add any comments necessary to support your

answers.

1. A consumer with behavioral challenges is yelling at and physically aggressingtoward a staff person. The employee is clearly frustrated. She responds by askingthe consumer if he would like to go to his room and calm down.

Is this maltreatment? Yes/No

2. A staff person is low on cash and would like to buy a can of pop. She borrows adollar from one of the consumers at the home where she works. The consumertells her it is OK with him if she does so. She says she will repay him thefollowing day. Is this maltreatment? Yes/No

3. A staff person takes a consumer to her art class at a local community center. Shedrops the consumer off at the door of the center and says she will be back in twohours. The consumer is unable to find her classroom and walks around the

building and neighborhood for several hours until she can be located.Is this maltreatment? Yes/No

4. A staff person runs a bath for a consumer and assists her into the tub. Theconsumer is physically challenged and non verbal. The staff person leaves theconsumer in the bathtub while she takes a phone call. Upon returning, theconsumer is unconscious and scalded. The staff person did not assess the watertemperature and it was extremely hot. Is this maltreatment? Yes/No

5. A consumer and a staff person decide to date and be physically intimate witheach other. The consumer is his own guardian. Both indicate they arecomfortable with this choice. Is this maltreatment? Yes/No

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