SUBMIT PRINT

EMPLOYMENT APPLICATION
Mains’l Services, Inc. is an Equal Opportunity & Affirmative Action employer. All qualified applicants will receive consideration
without 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 of
the Human Resources Department.
PERSONAL INFORMATION
Last Name First Name Middle Initial Date of Application
SUNDAY ARO TITILAYO 07/05/2010
Address City, State Zip
965 APT.8 AVON STRRET ST PAUL MN55103
Home Telephone Number Alternate Telephone Number E-Mail Address
651 -207-9146 651-207-9146 WALETOKUNBO@YAHOO.COM
If hired, can you present proof of legal authorization to work in the United States? YES NO
If hired, you will be required to provide documentation verifying citizenship or eligibility to work in the United States
Are you under the age of 18? YES NO

Do you have a valid driver’s license? YES NO Minnesota

If yes, valid in what State: __________________________

Do you have valid automobile insurance? YES NO

Have you ever been convicted of a felony? YES NO

Conviction of a felony does not automatically disqualify you from employment.

Date of conviction:

If yes, please explain:

Have you ever applied for employment with Mains’l Services? YES NO

Have you previously been employed by Mains’l Services? YES NO

If yes, under what name? SUNDAY ARO Dates of employment: 03/2010

Position(s) held: PCA

AVAILABILITY
Position applying for Requisition Number Salary Requirements
PCA 37562 7.5
Number of hours desired FT PT (# OF HOURS PER 2 WEEKS _________________)
35 CASUAL/ON-CALL

Shift desired Day Evening Overnight Weekdays Weekends All Shifts Other

07/06/2010
Date available to start work: ___________________________

EDUCATION
High School Did you graduate? Degree Earned
ORIWU HIGH SCHOOL YES NO WASC
College or University Did you graduate? Degree Earned
YES NO
Graduate School Did you graduate? Degree Earned
YES NO
List any other special skills, activities, training, or experience that you believe would be of value to Mains’l Services and/or the job(s) you
are applying for:
FIRST AID,LIFTING,HAVING AN EXPERIENCE IN WORKING WITH HIGHLY VUNERABLE INDIVIDUAL.
COOKING, CLEANING.
PROFESSIONAL LICENSE/CERTIFICATIONS
License/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

REFERENCES
PLEASE LIST 3 PROFESSIONAL WORK REFERENCES. DO NOT INCLUDE FRIENDS OR RELATIVES.
Name Relationship Phone number and e-mail address
STACY ROE CDO MANAGER 763 416 9146
Name Relationship Phone number and e-mail address
JUDY ALBERTA CLIENT 952 936 9642
Name Relationship Phone number and e-mail address
FOLAKE ADELAKUN NURSE 651 238 3975
EMPLOYMENT HISTORY

Starting with your Current or Last Employer, PLEASE LIST ALL JOBS YOU HAVE HAD for the past seven (7) years. It is optional to
provide dates of employment for jobs held more than seven (7) years ago. Do not omit work experience just because it may be
unrelated to the job for which you are applying. IT IS REQUIRED THIS SECTION BE COMPLETE EVEN IF YOU ARE PROVIDING
A RESUME.
Current/Last employer name
MAINLS SERVICES,INC
Address City, State Zip code
7000 78TH AVENUE NORTH BROOKLYN PARK, 55445
May we contact? YES NO Person to contact Phone number
STACY ROE 763 416 9146
Your supervisor’s name and phone number Reason for leaving
STACY ROE 763 416 9146 DUE TO DEATH OF THE CONSUMER.
Employed from (month, Employed to (month, year) FT PT Casual/On-Call Job title
year) 2010 MARCH PERSONAL CARE ATTENDANT
Description of job duties
TRANSFERING THE CLIENT FROM THE WEEL CHAIR TO THE BATHROOM,CLEANING,COOKING,ERRANDS,AND
OTHERS
Salary Per Hour Year Bonus or other compensation
7.5

Employer name
PUNCH NEWS PAPERS
Address City, State Zip code
IKEJA, LAGOS, N IGERIA 234
May we contact? YES NO Person to contact Phone number

Your supervisor’s name and phone number Reason for leaving

AYANKUNBI 234 8120707999 RELOCATION
Employed from (month, Employed to (month, year) FT PT Casual/On-Call Job title
year)2001 ,FEBUARY JANUARY 2005 CIRCULATION EXECUTIVE,MARKETING OFFICER
Description of job duties
INVOLVING IN DISTRIBUTION OF THE NEWSPAPERS AND MARKETING OF THE PRODUCTS.

Salary Per Hour Year Bonus or other compensation

52,000

Employer name
WAVELINK GLOBAL IN VESTMENT LTD
Address City, State Zip code
ABUJA FCT ABUJA 09
May we contact? YES NO Person to contact Phone number
MARY TALOR 0802443563
Your supervisor’s name and phone number Reason for leaving
MARY TALOR 0802443563 RELOCATION
Employed from (month, Employed to (month, year) FT PT Casual/On-Call Job title
year) 2006,APRIL MARCH,2009 BUSINESS MANAGER
Description of job duties
FACILITATING THE BUSINESS TANSACTIONS,MEETING THE CUSTOMERS SEE TO THE DAY TO DAY
ACTIVITIES OF THE ORGANISATION
Salary Per Hour Year Bonus or other compensation
58,000
PLEASE EXPLAIN ANY GAPS IN EMPLOYMENT
 STATEMENT, AUTHORIZATION AND RELEASE
PLEASE 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. I
understand that falsification or omission of information provided by me may disqualify me from consideration for employment
or 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 Mains’l Services Inc. I understand and agree
that if I am offered and accept employment with Mains’l Services, my employment is for no definite period and may be
terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Mains’l
Services. I understand that no supervisor or representative of Mains’l is authorized to make any assurances to the contrary
and that no implied oral or written agreement are valid unless they are in writing and signed by the Chief Executive Officer or
Vice President of Human Resources.

_____I authorize any person or organization referenced in this application to give representatives of Mains’l Services any and all
Information 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 that
may result from furnishing such information to Mains’l Services, Inc. I authorize Mains’l Services, Inc. and/or their
representatives to request and receive such information. Mains’l Services may also investigate my driving record and criminal
record. I understand my application may be released to social services or other regulatory agencies for the purpose of
fulfilling Mains’l Services licensing requirement.

_____I understand that any offer of employment will be contingent upon successful completion and clearance of: proof of legal
authorization 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 Fair
Credit Reporting Act, the California Consumer Investigative and Credit Reporting Agencies, or Minnesota Statute, Acts and in
accordance with the Federal Trade Commission, I understand that I have the right to request a complete and accurate
disclosure of the nature and scope of the investigation requested. I am entitled to know if employment is denied because of
information obtained by Mains’l Services from a Reporting Agency.

_____If employed by Mains’l Services, I agree to follow all rules, policies, and procedures, and that they may be changed at any time
at the discretion of Mains’l 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 3.25

SIGNATURE SUNDAY ARO DATE

07/05/2010
 EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

Mains’l 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 be
kept separate from you’re application and employee file. If you choose not to, then your decision will not affect your
employment opportunity with Mains'l Services, Inc.

Thank you for your help and cooperation!

Gender (please check only one)

FEMALE
MALE
DO NOT WISH TO DISCLOSE
Race/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, o
the Middle East.

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

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

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

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

AMERICAN INDIAN OR ALASKA NATIVE: all persons having origins in any of the original peoples of North
America and who identifiable tribal affiliations through membership and participation or community recognition.

TWO 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 mental
impairment (or condition) that materially (or significantly) limits one or more major life activities; having a record o
such 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 EEO
Forms in the personnel file.
 Mains’l Services Inc
Program Specialist Assessment

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

Name: STACY ROE Date: 07/05/2010

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 non–verbal; she does understand and makes
some sound for communication. She enjoys watching Walt Disney movies. The two
of you are watching TV. The program you are watching is a talk show that you want
to watch. Lily starts to scream.
I WILL ALLOW LILY TO WATCH HER PROGRAMME, OR WALT DISNEY MOVIES.
BECAUSE CONSUMER/CLIENT INTEREST COME FIRST.

1
Mains’l 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, 2004
he goes to the movies and spends $4.50 for his ticket and $4.00 for popcorn and
pop. On Saturday, May 8th, Ken goes shopping at Target and buys a T-shirt and
a pair of shorts for $12.00. Sunday afternoon, May 9th, Ken stops at Dairy
Queen and buys an ice cream cone for $1.25. How much money does Ken have
left at the end of the weekend?

Complete Ken’s 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 to
eat at McDonalds. Staff spends $4.39 on a meal. How much petty cash is left
from the purchase?

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

2
MAINS'L SERVICES, INC.
CASH RECORD SHEET

NAME: KEN"S
MONTH/YEAR: MAY,2004
CASH
RECEIPT TRANSACTION STAFF BEGINNING BALANCE 25.00
DATE NUMBER DESCRIPTION CHECK # INITIALS DEPOSIT PAYMENT BALANCE

07 01 MOVIES TICKET 01 S.A 25 4.50 20.50

07 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

TOTALS 25.00 21.75 3.25

CASH BALANCE CARRIED FORWARD 3.25

*Bank withdrawal must also be listed as cash deposit.

MAINS'L SERVICES, INC.
PETTY CASH LEDGER SLS: Bank Balance $
Month/Year: MAY,1ST Beginning Cash Balance$ 10.00
CHECK ONE
STAFF CASH EXPENSE/
DATE RECEIPT # Groc Prog Supp SITE OF PURCHASE ITEM PURCHASED INITIALS DEPOSIT WITHDRAWAL BALANCE

01 01 MACDONALD BURGER S.A 10.00 4.39 5.71

Ending Cash Balance$ 5.71

Total Cash Expenditures $_________
4.39

Total Bank Expenditures $_________ Ending Bank Balance

TOTAL EXPENDITURES $__________
4.39

P. M. Signature (Rev. 1/26/94)

Mains’l Services Inc
Program 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 May
29, 2004. He lives at 4900 Hemlock Lane in Maple Grove. He tripped on a rock and
fell to the ground. He got up on his own but his right knee was bleeding and had an open
scratch 2 inches long. Medical attention was not required.

3
 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.
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)

Mains’l 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 aggressing

toward a staff person. The employee is clearly frustrated. She responds by asking
the 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 a
dollar from one of the consumers at the home where she works. The consumer
tells her it is OK with him if she does so. She says she will repay him the
following day. Is this maltreatment? Yes/No

3. A staff person takes a consumer to her art class at a local community center. She
drops the consumer off at the door of the center and says she will be back in two
hours. 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. The
consumer is physically challenged and non – verbal. The staff person leaves the
consumer in the bathtub while she takes a phone call. Upon returning, the
consumer is unconscious and scalded. The staff person did not assess the water
temperature and it was extremely hot. Is this maltreatment? Yes/No

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