Empire Resources, LLC

Application details

A few quick facts about this application.

Application date

Job title

Application type

New hireRehire

Gender identity

MaleFemaleNon-binary

Intake person

Intake person phone

Intake person email

Personal information

All names must match your government ID exactly.

Legal first name

Must match ID

Legal full middle name

Legal last name

Include Sr/Jr if applicable

Middle initial

Other last names used

Driver's license / ID number

State of issuance

ID expiration date

Place of birth (state)

Social Security number

Date of birth

Age

Street address

Residential — no PO boxes

Apartment number

City

State

ZIP code

County

Phone number

Background & employment history

Inaccurate information may delay your background study.

Are you 18 or older?

YesNo

If under 18, you may affiliate with only one agency.

Previous Empire employee?

YesNo

Lived outside Minnesota in the last 5 years?

NoYes

Current name on MN IT'S

If different from above

Work for another agency?

If yes, list the agency name

Client & service history

Have you received services in the past 12 months?

YesNo

Emergency contact

Name and phone number

Notes

Certifications & numbers

UMPI

If requesting reinstatement

PCA certificate date

PCA certification number

If known

Application number

BGS number

Agency personnel completing form

Document uploads

PDF, JPG, or PNG. Front and back where applicable.

Driver's license / state IDClick to upload (PDF, JPG, PNG)

Front and back, single file or combined

Social Security card or birth certificateClick to upload (PDF, JPG, PNG)

Certified copy if using birth certificate

PCA / CFSS certificateClick to upload (PDF, JPG, PNG)

Required to work as a PCA / Support Worker

Acknowledgments & consent

I have received and reviewed the Empire Resources policy & procedure manual, Provider Agreement Summary, and Privacy Notice.

Medical reimbursement plan

I do NOT wish to participate in the tax-free, employer-sponsored Minimum Essential Coverage PlanI want to participate in the Minimum Essential Coverage Plan

My electronic signature is my legally binding signature.

Initials

2 characters; 3 if you have a middle name

Preferred method of contact

MailEmailPhone

Questions for us?

Optional — leave blank if you have none.

Question 1

Question 2

Question 3

By submitting, you confirm that the information above is accurate to the best of your knowledge.

Start yourEmpire journey.

Start your
Empire journey.