2903 15th Street South
Moorhead, MN 56560
Phone: 218-236-6730
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Please complete as thoroughly and completely as possible. Applications not thoroughly completed may be rejected.
Fields with '*' are required.
Position Applying for:
Legal Name First * Middle * Last *
Email Address *
Street * City * State Zip Code *
Best daytime phone *
  - -
List all other names(maiden name, etc) Last 4 digits of Social Security Number *
Have you ever applied with CCRI before?
If yes, when?
Have you ever been employed by CCRI?
If yes, when?

How were you referred to CCRI?
1. Employee - Full Name of Person who referred you: 2. Client or Case Manager - person who referred you:
3. From one of the following: 4. Other - Describe:

1. Please tell us why you are interested in employment with CCRI:
2. What top 4 qualities do you have that make you a great candidate for the job you are applying for:
3. List any volunteer work you have done or special certifications you have:

Please list the name, address and phone number of three work-related references (excluding relatives) who have specific knowledge of your skills, qualifications, and abilities to perform in the position you are applying for.
If no work experience, provide 3 character references
First & LastName *   City * State Business Phone * How do you know them? Explain
  - -
First & LastName *   City * State Business Phone * How do you know them? Explain
  - -
First & LastName *   City * State Business Phone * How do you know them? Explain
  - -

Employment History 1: List your MOST RECENT employer first. Be as detailed as possible.
Employer Name *   City * State Business Phone * Ending Salary
  - -
Supervisor First & Last Name * Currently Employed Employment Dates (Use Date Format: --/--/----) Position Held *
Start *:  Calendar  End *:  Calendar 
* Job Duties:
* Reason for Leaving:

Employment History 2:
Employer Name *   City * State Business Phone * Ending Salary
  - -
Supervisor First & Last Name * Employment Dates (Use Date Format: --/--/----) Position Held *
Start : * Calendar  End : * Calendar 
 Job Duties:  *
 Reason for Leaving: *

Employment History 3:
Employer Name   City State Business Phone Ending Salary
  - -
Supervisor First & Last Name Employment Dates (Use Date Format: --/--/----) Position Held
Start: Calendar  End: Calendar 
Job Duties:
Reason for Leaving:

Please list any gaps in work history:

Name & Location Last Year Completed Did you Graduate? Course of Study
High School (GED)

READ THIS INFORMATION CAREFULLY BEFORE ANSWERING THE FOLLOWING QUESTIONS: The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, creed, religion, sex or national origin. Federal law also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits and participation in union activities. The following information is needed for the position for which you are applying for a legally permissible reason, including, without limitation, national security requirements, affirmative action, a bona fide occupational qualification or business necessity.
Are you age 18 or older? Are you authorized to work in the United States on a full-time basis for all employers, or for your current employer only?  
Are you able to perform the duties of the position you are applying for? * Do you have a current driver's license? * Do you have a clear driving record?  *
If no, please explain:
Specific to Position Applying For (Clinical/Caregiver positions)
Do you have a vehicle you can use on the job to provide transportation for clients? Can you show proof of liability insurance on your automobile?

Please indicate the times you are available to work:
Start Time a.m/p.m End Time a.m/p.m Preferred Shift Length: Departments Interested In:

Saturday: Other:
Comments on availability /or specific site interested in:
Are you available to work weekends? If so, how many weekends per month would you be willing to work? Preferred number of hours per week: *
Do you prefer a set schedule? Set Schedule Comments:
Are you willing to work split shifts? Split Shift Comments:
I am seeking a job for: *
I want to work during the school year only. Expected Graduation Date: Calendar (Use Date Format: --/--/---- )
I am interested in working more hours during the summer and less hours during the winter:

Pre-Employment Statement
(Please read carefully and sign the statements below.)
"Name" and "Date" fields are required. Your application will be denied if they are not filled in!
1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination.

2. Any offer of employment I may receive from CCRI is contingent upon my successful completion of the company’s pre-employment screening process, including receiving references that it considers satisfactory.

3. I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of CCRI. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to CCRI.

4. In processing my application for employment, CCRI may verify all the information I have provided. All employees are required to pass a Minnesota State criminal background check. According to Minnesota statutes MSP Section 299c.62 (Criminal Background Checks for Children's Service Providers) and MSA Chapter 245c (Criminal Background Checks for Personal Care Providers) all CCRI employees are required to pass a Minnesota State background check. Please refer to the Background Study Privacy Notice. I acknowledge and understand these requirements and I authorize CCRI to submit the required information to the Department of Human Services to complete this check. Unfavorable responses from the state will result in the withdrawal of any employment offers that have been made.
* Type Your Name: * Date:   Calendar   (Use Date Format: --/--/---- )
NOTE: A typed signature is the same as a handwritten signature of acknowledgement.
5. I authorize and request that all of my present and former employers and those individuals I have listed as personal references to furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information.
* Type Your Name: * Date: Calendar   (Use Date Format: --/--/---- )
6. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the company and understand that my compensation and conditions of employment can be changed by the agency at anytime. I understand that any employment relationship with the agency is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge at any time with or without cause. I further understand that no manager or representative of the company, other than the Executive Director has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the foregoing. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and the individual designated above.
* Type Your Name: * Date: Calendar   (Use Date Format: --/--/---- )
* By entering your name in this field, you are authorizing CCRI to contact your references and check your employment history.
* Do not submit your application before this line is completed.
No Smoking Policy: CCRI employees are not allowed to use tobacco during work hours, in the presence of the people we serve, or on any CCRI property.
Drug & Alcohol Policy:For the safety and well being of all of our clients and employees, CCRI maintains a drug / alcohol free work envionment.

Minnesota Department of Human Services Licensed Facilities
Educational Programs, Temporary Employment Agencies, Professional Services Agencies
Background Study Privacy Notice

Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data Practices Act requires that you be informed of the following:
1. Purpose and intended use of the information: Minnesota statutes, chapter 245C, requires the Minnesota Department of Human Services (DHS) to conduct background studies on individuals providing direct contact services to people receiving services from facilities and agencies licensed by DHS. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS.
2. Whether you may refuse or are legally required to provide the information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study.
3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified.
4. Known consequences that will arise from refusing to supply the requested information: Only items identified as “optional” may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact to persons receiving services.
5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, the Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The information about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent.
Dated: 9/2003

Acknowledgment of Employer’s Right and Need
Motor Vehicle Report (MVR) Information

The goal of CCRI is to reduce the frequency and severity of accidents. An activity that supports that goal is screening of driver records. Applicants and employees whose regular job duties involve driving a company vehicle or their personal vehicle on company business on a regular (daily/weekly) basis will have driving records screened upon hire and at a minimum annually thereafter at the companies discretion. Screening is accomplished via reviews of Motor Vehicle Reports (MVRs). A MVR shows if a driver’s license has been suspended or revoked. A MVR also reflects violation and/or accident history.

Why is this important? A history of accidents and traffic violations reflects driving attitudes and habits. Those attitudes and habits are predictors of future accident experience. Employer and employees understand that use of these records is limited to employer’s obligation to comply with the underwriting process relating to securing insurance coverage.

In accordance with the provisions of the Fair Credit Reporting Act, Public Law No. 91-508, CCRI certifies that the information requested below will be used for a “permissible purpose” as defined in the Act, and that the information received will be used for no other purpose. It is further certified that the source of the reports will be identified if employment decisions (based on report results) are made. Motor Vehicle Reports will be treated in a confidential manner. In accordance with the Drivers Privacy Protections Act, Public Law 103-322, data obtained will be used for permissible purposes only.

CCRI checks motor vehicle records for the past 3 years. Any “Type A” violations (DUI, excessive speed, driving without a license, running from law enforcement, etc.) would be immediate disqualifiers. Other types of violations would depend on the number and circumstances. We would recommend that you review your driving record prior to application if there is a concern.

Last Name: First Name: Middle Name: Birth Date: * ( Use Date Format: --/--/---- ) Calendar   
Drivers License Number: * State of Issue: * License Expiration Date: * ( Use: --/--/---- ) Calendar 
This form authorizes employer to check my Motor Vehicle Record periodically without further consent.
This authorization expires upon termination of my employment.
* Type Your Name: * Date: Calendar   ( Use Date Format: --/--/---- )


In an effort to comply with requirements regarding record keeping, reporting and other legal obligations, which may apply, we invite you to complete this applicant data survey. This form is to be completed by each applicant on a voluntary basis. This is not for interview purposes. This form is to be filled out separately from the application. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. This information will be used and kept confidential in accordance with applicable laws and regulations.
Position Applied For: If Other: Date Applied: (Use: --/--/---- ) Calendar 
Applicant Information:
Name: Gender:
Select one of the following Equal Employment Opportunity Identification Groups:

Resume/Letter of Interest
Files with extensions .doc, .docx, .pdf, .txt, .xls, .xlsx are only allowed!
If you have a resume, attach it here: If you have a letter of interest, attach it here:

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