Application & new-employee onboarding — one guided flow.
Federal Form I-9, Section 1 (Employment Eligibility Verification, USCIS). Federal law requires
every U.S. employee to complete Section 1 no later than the first day of employment (8 U.S.C. §1324a; 8 CFR §274a.2).
Enter your information exactly as it appears on your documents. On or before your first day, bring your original
document(s) from the I-9 Lists of Acceptable Documents (e.g., U.S. passport, OR driver’s license + Social Security card
or birth certificate) so the office can complete Section 2 within 3 business days. If someone helps you prepare or translate
this form, tell the office — Supplement A must be completed.
1. Your Information
2. Citizenship / Immigration Status
I attest, under penalty of perjury, that I am (check ONE):
Provide ONE of the following:
3. Attestation & Signature
I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents,
in connection with the completion of this form. I attest, under penalty of perjury, that the information above, including my
selection of the box attesting to my citizenship or immigration status, is true and correct.
Employee signature
Equal opportunity & your privacy Bella Mente, Inc. is an equal opportunity employer. Consistent with Minnesota law (Minn. Stat. §364.021), this application does not ask about criminal history; direct-care employment is conditioned on a Minnesota DHS background study (Minn. Stat. ch. 245C) after a conditional offer. If you need an accommodation to complete this application, contact our office.
1. Applicant Information
Are you legally authorized to work in the United States?
Are you 18 years of age or older?
Do you have a valid driver’s license and reliable transportation?
Have you served in the U.S. military?
2. Employment History
Start with your current or most recent employer.
Employer 1 (current or most recent)
May we contact this employer?
Employer 2
May we contact this employer?
Employer 3
May we contact this employer?
3. Education & Training
High school
College / university
Trade or technical school
Other
4. Availability
List the hours you are available each day (e.g., 8am–2pm; overnight).
5. References
Reference 1 (professional)
Reference 2 (professional)
Reference 3 (personal or professional)
6. Service Preferences
Which services are you interested in providing? (check all that apply)
Comfortable working with persons or homes that include: (check all that apply)
Transportation available:
Any allergies that could affect working in a client’s home?
7. Required Training & Certifications
CareCertify training — required and paid (245D positions) All staff providing 245D services must complete Bella Mente’s required orientation and annual training, delivered through CareCertify, before providing direct support (Minn. Stat. §245D.09, subds. 4–4a). You do NOT need this before applying — it is provided after hire, and this mandatory training time is paid work time at no less than the 2026 Minnesota minimum wage of $11.41/hour.
Do you currently hold a DHS Individual PCA / CFSS training certificate?
The DHS individual PCA/CFSS course and test are free at registrationcourses.dhs.state.mn.us. If you already have your certificate, upload a photo or screenshot of it below.
DHS PCA / CFSS training certificate (upload if you have one)
Other relevant training certificate — CPR, First Aid, CNA, med administration, etc. (optional)
8. Direct-Care Experience (PCA / CFSS applicants)
Do you have experience as a PCA / CFSS worker or caregiver?
Comfortable assisting clients with bathroom / toileting needs?
Comfortable assisting with a range-of-motion program?
Comfortable assisting with a bowel program?
9. Certification & Signature
I certify that the information on this application is true and complete to the best of my knowledge. I understand that falsified or omitted information may disqualify me from consideration or result in dismissal if hired. I authorize Bella Mente, Inc. to contact the employers I have approved above and my listed references regarding my work record. I understand that any offer of employment for a direct-care position is conditioned on the satisfactory completion of a Minnesota DHS background study under Minn. Stat. ch. 245C, and that employment is at-will.
Applicant signature
Employee signature
Why we are asking (Minn. Stat. §13.04; §245C.05). This information submits your DHS background study via NETStudy 2.0 and verifies your identity at fingerprinting. It is private data. After submitting: DHS emails you a consent link, the fingerprint vendor emails you to schedule, and you may not begin direct-contact work until cleared (ch. 245C). Fingerprints are not retained after the check; your DHS photo is retained for identity verification; you may request reconsideration if disqualified (§245C.21).
Photo of government-issued ID (front)
Photo of Social Security card
I certify this information is true and matches my ID. I authorize Bella Mente, Inc. to submit it to DHS via NETStudy 2.0 and authorize DHS to obtain criminal history from the BCA, MN courts, other states, the FBI where required, and prior studies, ongoing while I am affiliated with this agency. I acknowledge the §245C.05 subd. 6 notice; an electronic signature is valid (§245C.05, subd. 9).
Applicant / employee signature
Form W-4 (2026) — Employee's Withholding Certificate. Complete Step 1 and Step 5; Steps 2–4 only if they apply. Your entries are placed onto the official IRS form, which is archived with your signature. The employer section is completed automatically for Bella Mente, Inc.
Step 1 — Personal Information
Filing status (choose one):
Step 2 — Multiple Jobs or Spouse Works (if applicable)
Step 3 — Claim Dependents (if applicable)
Step 4 — Other Adjustments (optional)
Step 5 — Sign Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee signature
Employer Section (completed by Bella Mente)
Form W-4MN — Minnesota Withholding Allowance/Exemption Certificate. Complete Section 1 (allowances) or Section 2 (exemption), not both. Entries are placed onto the official Minnesota Revenue form and archived with your signature.
Employee Information
Marital status:
Section 1 — Determining Minnesota Allowances
Section 2 — Exemption From Minnesota Withholding (only if it applies)
Sign Here
I certify all information is correct. I understand there is a $500 penalty for filing a false Form W-4MN.
Employee signature
Employer Section (completed by Bella Mente)
1. Employee Information
2. Authorization
I authorize Bella Mente, Inc. (the “Employer”), directly or through its payroll service provider, to deposit my net wages by initiating credit entries to my account(s) at the financial institution(s) listed below, and I authorize each financial institution to accept and credit those entries to my account(s).
If funds are ever deposited into my account in error, I authorize the Employer or its payroll provider to reverse the erroneous credit entry, not to exceed the amount of the error, in accordance with applicable NACHA operating rules. Any other recovery of amounts from my wages will occur only as permitted by Minnesota law (Minn. Stat. §181.79), which requires my separate, voluntary written authorization after the claimed debt arises.
I understand that I may decline or revoke this direct deposit authorization at any time by written notice, without retaliation, and that I have the right to be paid by other lawful means. This authorization remains in effect until the Employer receives my written termination notice and has a reasonable opportunity to act on it.
Paycard note (Minn. Stat. §177.255) Payment to a payroll card account requires your separate, voluntary written consent and cannot be a condition of hire or continued employment. If you use a paycard, set it up below as a checking account and contact the card issuer for the routing and account numbers.
3. Account 1 (primary)
Account type:
4. Account 2 (optional)
Account type:
5. Signature
Attach or bring a voided check (not a deposit slip) for each account so the office can verify the routing and account numbers.
Employee signature
Employee Responsibilities / Job Description. This agreement is between Bella Mente, Inc. and you, the Employee. Type your initials next to each item to confirm your understanding.
I am completing this agreement as:
As an employee, I am responsible for providing assistance to the client in his/her home, following a plan and working within the hours authorized. Bella Mente is the Employer & Fiscal Intermediary; the Responsible Party has daily supervision and scheduling responsibility. To be paid, I must be physically present and working with the Client or providing a service according to the plan.
Policies & Job Requirements — initial each
1. I will not be paid by Bella Mente to work during the time when there are no hours remaining for the Participant, the Client is ineligible for service, PCA/CFSS has no provider number, or the Client has an unpaid spend-down that must be paid to Bella Mente.
2. The Responsible Party has reviewed the following with me: Policy and Procedure Manual, Coordinated Service and Support Plan (CSSP) and/or Plan Addendum, Individual Abuse Prevention Plan (IAPP), and participant-specific information (which may include medications, safe lifting and transfers, seizure protocols, communication styles, and any other area identified by the Responsible Party). The Responsible Party will provide updates/changes related to the Participant's health or medication needs, and I agree to communicate any health or training concerns directly to the Responsible Party. The Policies and Procedures, CSSP or Plan Addendum, and IAPP should be available to me at all times. I understand 18 is the minimum age required to work for Bella Mente.
3. I agree to submit current copies of any degrees, licenses, or certifications that I hold.
4. I agree to complete orientation and annual training required by Bella Mente and submit required documentation. Failure to complete or show competency could result in termination of my employment.
5. In the event of a medical emergency, employees cannot transport a client to the hospital. CALL 911.
6. I am employed to meet the health and safety needs of the Client and will report concerns to the Responsible Party and/or Bella Mente. I will not engage in any verbal or physical misconduct. I will not be abusive or sexually harass the Client or anyone else.
7. I cannot violate the Vulnerable Adult Act or Maltreatment of Minors Act and will complete this training within 72 hours of providing direct contact services and annually thereafter. I will not engage in any unsafe practices. I am a mandated reporter of abuse and/or neglect; it must be reported to the Minnesota Adult Abuse Reporting Center and Bella Mente, or 911. Refer to the Vulnerable Adult and/or Maltreatment of Minors Policies.
8. To make certain the Client is properly cared for, I will call at least 8 hours in advance if I cannot arrive on time. My employment can be ended for not showing up, repeated tardiness, or leaving my shift early. I have a legal responsibility to notify the Responsible Party if I am not returning to cover the next shift; I can be charged with abandoning the Participant.
9. I cannot be paid for time worked when the Client is out of the home (e.g., at school, receiving in-patient care, in a hospital, nursing home, jail, or crisis respite facility). If the Client is admitted to the hospital, I will notify Bella Mente.
10. I cannot bring any outside work with me to the job, including personal projects, crafts, homework, or video games.
11. I cannot bring my own children or anyone else to work, and cannot care for other individuals in the home who are not receiving services. Unless it is an emergency or work-related, I cannot use my cell phone, text message, or access the internet for personal use.
12. I cannot possess, consume, or be under the influence of alcohol or illegal drugs, controlled substances, or unauthorized drugs when reporting to work or while working, including unauthorized use of legal drugs or prescriptions. Smoking is not permitted while working with a participant.
13. I will treat information about the Client as private. I cannot discuss Participants with anyone except Bella Mente or the Responsible Party, and will not take or display photos or videos of the Client without written permission from the Client and/or Responsible Party.
14. Any communications or concerns directed to Bella Mente's Administrative Office shall be made in a professional and respectful manner. Verbal abuse will not be tolerated.
15. I will update Bella Mente's Administrative Office, in writing, of any changes in my status, including address, telephone numbers, name, dependents, changes in tax exemption, changes to my employment status, and other pertinent or legally required information.
16. I am not guaranteed ongoing employment. Bella Mente may terminate my employment at will and without notice, and I can quit at will and without notice; however, consideration for re-employment shall be conditional on giving a two-week notice and leaving in good standing. A final check will be sent within the payroll cycle, or when all correct, completed time sheets are received.
17. Under the Minnesota Personnel Record Statute, I have access to my personnel file and may receive copies of documents in my file. The full policy is available from Bella Mente's Administrative Office.
18. It is my responsibility to notify the Responsible Party and the HR department at Bella Mente's Administrative Office of any work-related injury within 24 hours of the injury.
19. With the exception of respite, prior approval is required from Bella Mente before working overtime. Overtime is more than 40 hours in a work week.
20. EACH DAY, I (not the Responsible Party) will record on my time sheet the time I start and stop work, including a.m. and p.m. Late, incomplete, unsigned, or illegible time sheets will be returned for correction and will delay pay. I am required to write my employee number and phone number on my time sheets.
21. Time sheets must be emailed or faxed in PDF format by the deadline for each pay period; refer to the Payroll Calendar.
22. I cannot be asked or told to split pay with the Client or Responsible Party. This is FRAUD.
23. I understand fraud will not be tolerated. Refer to the Fraud Policy.
24. I will abide by Bella Mente's Policies and Procedures, which the Responsible Party fully reviewed with me.
25. I understand federal fraud checks are conducted upon employment and monthly thereafter.
26. I understand Bella Mente will conduct required criminal background checks, and if I fail to pass any required background check or study, Bella Mente may terminate my employment in its sole discretion.
27. NEW OR RE-APPLYING EMPLOYEES ONLY: I understand I am not able to start working until the Responsible Party has been notified by Bella Mente's Management Department. If I submit a timesheet for hours worked before my authorized start date, I will NOT be paid for those hours.
Acknowledgment & Signatures
By my signature below, I acknowledge, understand, accept, and agree to comply with this agreement. No oral statements can change any provision. This document supersedes all prior agreements. If I violate these or other Bella Mente policies, my employment may be terminated.
Employee signature
Bella Mente representative signature
DHS-4611 — MHCP Individual Direct Support Worker (CDCS, CSG, PCA, CFSS) Provider Agreement. By signing you agree to the provider conditions on the official DHS form: documentation standards under Minn. Stat. §256B.0659; cooperation with DHS, DHHS, and the Medicaid Fraud Control Unit; accepting DHS payment as payment in full; nondiscrimination; safeguarding protected data (Ch. 13, HIPAA, and related laws); and the remaining terms A–P. The complete agreement text is embedded in the archived PDF — read it before signing. Electronic initials and signature are accepted (Minn. Stat. §325L).
