Last Name:      First Name: Middle Name:
Street:   City: State: Zip:
Home Telephone:   Telephone:    Ext:  

Email:

Are you legally eligible for employment in the U.S.?
Are you 18 years or older?
Have you ever worked for Beacon Community Services?
If yes, please check which entity:

Beacon Community Services   Emp_w/CCPComSrv   Capella Management Group   
CCP-Family Services               Capstone Services     Meriwether Ventures   
Community Connections Partnership
Why did you leave?
What position are you applying for?
Fulltime   PartTime   Temporary  
What date can you start?
  
Hours Available?
AM Hours   PM Hours   Over Night  
Can you accept a position that requires: Driver's LicenseUse of automobile
Do you have any accommodation needs, which may require adaptation of job duties, tasks or work enviroments?
If yes, describe such needs and explain how you can preform the job with the accommodation:
High School:
Street: City: State: Zip:
Number of years attended: Did you graduate?
College:
Street: City: State: Zip:
Course of Study: Did you graduate?
Other:
Street: City: State: Zip:
Course of Study: Did you graduate?
Do you have any other relevant experience, skills or qualifications?

Work Experience:
Begin with present or most recent employer
Employer: Telephone:
Street: City: State: Zip:
Supervisors Name: Title:
Position: Employment: Years Months
Duties performed:
Reason for leaving:
Employer: Telephone:
Street: City: State: Zip:
Supervisors Name: Title:
Position: Employment: Years Months
Duties performed:
Reason for leaving:
Other information you feel to be important:

Application Data Survey

(COMPLETION OF INFORMATION IS VOLUNTARY)
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition handicap, sexual orientation, or any other legally protected status.
Position(s) applied for:
Direct Service Counselor
Management/Supervisory position
Office/Support Service Staff
Other:

Referral Source:
Advertisement
Walk-in
Private Employment Agency
Relative
School
Government Employment Agency
Name of Source (If Applicable):
As required, we comply with government regulations including Affirmative Action obligations where they apply.
In an effort to comply with requirements regarding government record keeping reporting and other legal obligations, we ask that you complete the applicant data survey. Your cooperation is appreciated.
Please be advised that your survey is not a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.
Check one: Male     Female
Check one of the following Race/Ethnic Group:
Hispanic
Asian/Pacific Islander
American Indian/Alaska Native
Black
White
Check one: Disabled Non-disabled
TO BE COMPLETED BY APPLICANT – NOT FOR INTERVIEW PURPOSES – TO BE REOMOVED BY EMPLOYER AND FILED SEPARATELY.
DIRECT CARE QUALIFICATION STANDARDS

Please review this list of qualifications. This list is to be used to identify employee qualification standards for employment in positions that require contact with adults and children receiving services from CCP-Community Services. This is not a complete listing of all qualification standards but rather a listing of those most critical. If an offer of employment is made to you, these qualification standards will be checked through the State Bureau of Criminal Apprehension, local District Court records, Department of Criminal Apprehension, Department of Human Services, County Social Services Agencies and Local Police Departments. Any of these standards, as well as other employment requirements, may be a disqualification for that employment offer.
    1. Willingness to disclose your arrest, conviction and criminal history.
    2. Conviction of, or awaiting trail for or admission of any of the following crimes:
      • Possession, use, sale, manufacturing and/or distribution of illegal drugs and simulated illegal drugs (M.S. sections 152.09, 152.096, 152.097)
      • Murder, manslaughter, aiding a person in a suicide or attempted suicide (M.S. sections 609.185 to 609.215)
      • Assault, harm caused by a dog, mistreatment of persons confined, mistreatment of residents or patients, use of drugs to injure or facilitate crime, robber, kidnapping, false imprisonment, depriving another of custodial or parental rights or abduction (M.S. secitons609.221 to 609.265)
      • Coercion, attempt to coerce, interfering with religious observance, bestiality, leaving the state to evade establishment of paternity, prostitution and related offenses or certain criminal sexual conduct (M.S. sections 609.27 to 609.345)
      • Incest, malicious punishment of a child or neglect of a child (M.S. sections 609.365, 609.377, 609.59)
      • Theft, possession of shoplifting gear, bringing stolen goods into the state, or receiving stolen property, embezzlement of public funds (M.S. sections 609.52, 609.521, 609.225, 609.53, 609.54, 609.551, 609.821)
        • Arson, burglary, or possession of burglary tools (M.S. sections 609.561 to 609.563, 609.582, 609.59)
      • Forgery or aggravated forgery (M.S. sections 609.625 or 609.63)
      • Adulteration, riot or terroristic threats (M.S. sections 609.6872, 609.71, 609.713)
      • Incident exposure or use of minors in sexual performance (M.S. 617.23, 617.246)
    3. Subject of an investigation for or admission to abusing or neglecting an adult or child (M.S. section 260.221 paragraph b).
    4. Involuntary termination of your parental rights within the last 5 years (M.S. section 2610.221 paragraph b).
    5. Diagnosis of mental illness or mental condition.
    6. Abuse of prescription drugs.
    7. Use of controlled substances (M.S. Chapter 152).
    8. Abuse of alcohol.