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 reasons for any gaps in work history:

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

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?
Do you have a current driver's license? * Do you have a clear driving record?  *

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: *
Are you willing to work split shifts? 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, employment verifications, and successfully passing a criminal background check, per Minnesota statutes MSP Section 299c.62 and MSA Chapter 245c.

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.
* Type Your Name: * Date:   Calendar   (Use Date Format: --/--/---- )
NOTE: A typed signature is the same as a handwritten signature of acknowledgement.
4. 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: --/--/---- )
* 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.

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

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.

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


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.

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.

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: What is your gender:
Select one of the following Equal Employment Opportunity Identification Groups:
Are you disabled?   

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