TRI-COUNTY COMMUNITY CORRECTIONS

816 Marin Avenue, Suite 110

Crookston MN 56716

APPLICATION FOR EMPLOYMENT

Application for Classified Personnel Positions & Volunteers

Equal Employment Opportunity

It is the policy of Tri-County Community Corrections to provide equal employment opportunity for all, without discrimination on the basis of race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, disability, sexual orientation or age.

Data Privacy Notice

The information requested on this application is intended to be used by Tri-County Community Corrections in determining suitability for employment for the position which you are currently seeking or may seek in the future.

If hired, the information may later be used for consideration for other positions, verification of employment history or disciplinary action in the event that the information provided is not truthful. You are not legally required to provide any of the information on this form at this time. However, failure to provide complete, accurate information may result in Tri-County Community Corrections being unable or unwilling to offer employment to you.

With respect to any special accommodations necessary for completing your application or the interview process, Tri-County Community Corrections may be unable to provide the necessary accommodations if you do not provide the information under the Personal Data section.

The information on this application, which is classified as private data under the Minnesota Government Data Practices Act (MGDPA) will not be released outside Tri-County Community Corrections without your consent except as necessary for tax purposes or as otherwise required by State or Federal Law. Information which is classified as public data will be released pursuant to the terms of MGDPA.

Position Desired

Position for which you are applying: *

Are you looking for Full Time, Part Time or Either: *

Date available to begin employment: *

Personal Data

Last Name *

First Name *

Middle Name: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Email Address *

Are you either a U.S. citizen or legally eligible to hold employment in the United States? *

Have you previously worked for Tri-County Community Corrections? *

If YES, position held / department:

If YES, under what name may your previous employment records be found:

If you have any special needs which may necessitate accommodations in the application or interview process, please contact the Administration Office at (218) 470-8105 to make a request.

List all other names under which you have been employed or under which your employment or educational records may be found:

Work / Volunteer Experience

List all work and volunteer experience, whether or not relevant to the position, most recent first.

*

	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Employer (Company) Name:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Employer (Company) City:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Employer (Company) Phone Number:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Supervisor Name:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Your Job Title:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Your Job Duties:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Employment Start Date:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Employment End Date:	1. CURRENT OR PREVIOUS WORK EXPERIENCE
Reason for Leaving:	1. CURRENT OR PREVIOUS WORK EXPERIENCE

*

	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Employer (Company) Name:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Employer (Company) City:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Employer (Company) Phone Number:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Supervisor Name:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Your Job Title:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Your Job Duties:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Employment Start Date:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Employment End Date:	2. CURRENT OR PREVIOUS WORK EXPERIENCE
Reason for Leaving:	2. CURRENT OR PREVIOUS WORK EXPERIENCE

	3. PREVIOUS WORK EXPERIENCE
Employer (Company) Name:	3. PREVIOUS WORK EXPERIENCE
Employer (Company) City:	3. PREVIOUS WORK EXPERIENCE
Employer (Company) Phone Number:	3. PREVIOUS WORK EXPERIENCE
Supervisor Name:	3. PREVIOUS WORK EXPERIENCE
Your Job Title:	3. PREVIOUS WORK EXPERIENCE
Your Job Duties:	3. PREVIOUS WORK EXPERIENCE
Employment Start Date:	3. PREVIOUS WORK EXPERIENCE
Employment End Date:	3. PREVIOUS WORK EXPERIENCE
Reason for Leaving:	3. PREVIOUS WORK EXPERIENCE

	4. PREVIOUS WORK EXPERIENCE
Employer (Company) Name:	4. PREVIOUS WORK EXPERIENCE
Employer (Company) City:	4. PREVIOUS WORK EXPERIENCE
Employer (Company) Phone Number:	4. PREVIOUS WORK EXPERIENCE
Supervisor Name:	4. PREVIOUS WORK EXPERIENCE
Your Job Title:	4. PREVIOUS WORK EXPERIENCE
Your Job Duties:	4. PREVIOUS WORK EXPERIENCE
Employment Start Date:	4. PREVIOUS WORK EXPERIENCE
Employment End Date:	4. PREVIOUS WORK EXPERIENCE
Reason for Leaving:	4. PREVIOUS WORK EXPERIENCE

	5. PREVIOUS WORK EXPERIENCE
Employer (Company) Name:	5. PREVIOUS WORK EXPERIENCE
Employer (Company) City:	5. PREVIOUS WORK EXPERIENCE
Employer (Company) Phone Number:	5. PREVIOUS WORK EXPERIENCE
Supervisor Name:	5. PREVIOUS WORK EXPERIENCE
Your Job Title:	5. PREVIOUS WORK EXPERIENCE
Your Job Duties:	5. PREVIOUS WORK EXPERIENCE
Employment Start Date:	5. PREVIOUS WORK EXPERIENCE
Employment End Date:	5. PREVIOUS WORK EXPERIENCE
Reason for Leaving:	5. PREVIOUS WORK EXPERIENCE

Licensure

List current licenses, registrations or certificates relevant to the position for which you are applying.

All applicable licenses or certifications must be received in the Administration Office prior to employment commencing. If hired, you remain responsible for ensuring that all applicable licenses remain in effect.

	License #1	License #2
License / Number	License #1	License #2
Issued By	License #1	License #2
Date	License #1	License #2
Expiration	License #1	License #2

	License #3	License #4
License / Number	License #3	License #4
Issued By	License #3	License #4
Date	License #3	License #4
Expiration	License #3	License #4

Education / Training / Experience

Include high school and/or institution issuing GED and any additional education/courses taken.

Do not list dates of attendance for high school. List most recent first.

*

	School and/or Institution
Name of School	School and/or Institution
Location of School	School and/or Institution
Degree / Diploma Received	School and/or Institution
Major / Minor	School and/or Institution
Date(s) of Attendance	School and/or Institution

	School and/or Institution
Name of School	School and/or Institution
Location of School	School and/or Institution
Degree / Diploma Received	School and/or Institution
Major / Minor	School and/or Institution
Date(s) of Attendance	School and/or Institution

	School and/or Institution
Name of School	School and/or Institution
Location of School	School and/or Institution
Degree / Diploma Received	School and/or Institution
Major / Minor	School and/or Institution
Date(s) of Attendance	School and/or Institution

	School and/or Institution
Name of School	School and/or Institution
Location of School	School and/or Institution
Degree / Diploma Received	School and/or Institution
Major / Minor	School and/or Institution
Date(s) of Attendance	School and/or Institution

List/describe any other training and/or experience relevant to the position for which you are applying.

0/355 characters

References

These should be people in a position to discuss your qualifications for the position you seek. Include especially managers, directors or heads of departments under whom you have worked. Indicate any who are related to you.

Tri-County Community Corrections reserves the right to contact all prior employers, educational institutions or institutions where you have volunteered in addition to references listed below.

*

	Reference #1
Name of Reference	Reference #1
City / State	Reference #1
Contact Phone Number	Reference #1
Title / Relationship	Reference #1

*

	Reference #2
Name of Reference	Reference #2
City / State	Reference #2
Contact Phone Number	Reference #2
Title / Relationship	Reference #2

*

	Reference #3
Name of Reference	Reference #3
City / State	Reference #3
Contact Phone Number	Reference #3
Title / Relationship	Reference #3

Criminal Background Information

Have you ever been convicted [or charged] with a misdemeanor or felony? *

If YES, please explain the nature of the charge and the circumstances; including if you were convicted and/or did you plead guilty. Give the date, city, State and County where convicted.

0/300 characters

This section is to be completed ONLY if applying for NW Regional Corrections Center or Red River Valley Juvenile Center positions.

Prison Rape Elimination Act standards (115.17) requires that all applicants for employment in corrections facilities (adult or juvenile) answer the following three (3) questions:

Question #1: Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility or other institution? *

Question #2: Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force or coercion, or if the victim did not consent or was unable to consent or refuse? *

Question #3: Have you been civilly or administratively adjudicated to have engaged in the activity described in question number two? *

Tri-County Community Corrections will conduct a criminal background check on individuals upon making a contingent job offer. No offer of employment shall become final until receipt of the results of the criminal background check from the Bureau of Criminal Apprehension (BCA), the content of which is acceptable to Tri-County Community Corrections and formal approval by the Regional Corrections Board.

Veteran Status

Are you an honorably discharged veteran of the armed forces of the United States or are you otherwise eligible to claim Veteran's Preference Points?

Are you the spouse of a deceased honorably discharged veteran or disabled veteran who is unable to work due to such disability?

Do you wish to claim Veteran's Preference Points?

If you are a disabled veteran do you wish to claim additional points?

Proof of applicable military status/eligibility, such as a DD214 form, will be required in order to claim credits. Please forward a copy of the DD214 form within five (5) business days. If you receive a passing score, you will be shown your score upon request.

Prior Employment

Have you ever been discharged or forced to resign from prior employment, other than in relation to a human rights charge or lawsuit in which you were the claimant/plaintiff? *

If so, identify the employer and describe the circumstances.

0/300 characters

Personal Statement

Please indicate why you are interested in the position and what you hope to accomplish if selected.

0/300 characters

Unexcused Absences From Work

How many days were you inexcusably absent from work during the preceding three (3) years other than absences due to illness or injury of you or your immediate family?

0/300 characters

Certification, Acknowledgement and Release

I certify that the answers I have given on this application are true and correct to the best of my knowledge. I understand that any false or misleading information provided or any omission or concealment of facts, will disqualify me from consideration for employment and constitutes grounds for my immediate dismissal should I be employed by Tri-County Community Corrections.

I understand, acknowledge and agree that no offer of employment is valid or binding until formal approval by the Regional Corrections Board or the appointing authority and that until such approval Tri-County Community Corrections shall not be liable for any reliance on any oral or written offers of employment made to me.

In connection with this application I hereby authorize any and all current and former employers, organizations where I have volunteered ("volunteer organizations") and references named in this application or any agent of such a former employer or volunteer organization, to release to Tri-County Community Corrections and its agents any and all information regarding my job performance and fitness/qualifications to perform the position I am presently seeking and any other employment or related information, both public and private, in their possession.

I understand that Tri-County Community Corrections will use this information to determine my fitness/qualifications for the position I am seeking.

This authorization expires one year from the date of my signature below.

I hereby release Tri-County Community Corrections and all former employers, volunteer organizations and references listed herein and any and all agents acting on behalf of Tri-County Community Corrections, former employers, volunteer organizations or references, for any and all liability of whatever nature by reason of requesting or providing such information.

Signature: *

clear

Tri-County Community Corrections

Affirmative Action Information

This form will remain separate from your application and will no way affect you as an applicant for the position in which you have applied. The information on this form will ONLY be used in reporting on Equal Opportunity Employment. Furnishing the information is strictly voluntary.

Position applying for:

Sex

Age

Ethnic Group

White, not of Hispanic origin. Persons having origins in any of the origin of Europe, North Africa or the Middle East

Black, not of Hispanic origin. Persons having origins in any of the Black racial groups of Africa

Hispanic, persons of Mexican, Puerto Rican, Central or South American or other Spanish Culture or origin, regardless of race

American Indian or Alaskan Native, persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition

Asian or Pacific Islander, persons having origins in any of the original people of the Far East, Southeast Asia, the Indian Sub-Continent or the Pacific Islands. This area includes, for example: China, Japan, Korea, the Philippine Islands and Samoa

Do you have a disability:

If you are disabled, you are invited to volunteer this information. If you fail to volunteer this information it will not affect your consideration for employment.