Open interviews for program counselors are available every Wednesday from 2pm-5pm at 4670 Slater Road, Eagan MN 55122. Please bring a resume or complete our online application (below) prior to the open interview. To schedule an interview outside of the open interview time frame, email or fax resumes to (651) 379-4575. Questions may be directed to (651) 454-0161 x102.


Application for Employment

New Challenges, Inc. is an equal opportunity employer which selects the best matched
individuals for each position based on job related qualifications regardless of the applicant’s
race, color, creed, gender, national origin, age, disability, marital or veteran status, sexual
orientation or other protected groups under local, state or federal equal opportunity laws.

Fields marked with an asterisk (*) are required.

Date*:

Name*:

Address*:

Your Email*:

Social Security Number*:

Date Available*:

Phone Number*:

Salary Range*:

Availability: Please indicate the shifts you are available to work each day.

Sunday:  AM PM

Monday:  AM PM

Tuesday:  AM PM

Wednesday:  AM PM

Thursday:  AM PM

Friday:  AM PM

Saturday:  AM PM

Position desired:  Full time Part time Live-in Overnight

Do you know someone who is or has been employed by NCI?
 Yes No

If Yes, give names:

Are you presently employed?
 Yes No

May we contact your present employer?
 Yes No

Are you at least 18 years old?
 Yes No

Do you hold a valid Minnesota Driver’s License?
 Yes No

Driver’s License Number:

Do you have a vehicle to use for work purposes?
 Yes No

Do you have current vehicle insurance?
 Yes No

Have you had any moving violations in the past 3 years?
 Yes No

In the past two years, have you had at least 24 hours of documented training in the field of development disabilities and/or traumatic brain injuries?
 Yes No

If Yes, where:

Please describe any specialized training, skills, licenses or certificates you have which may aid you in the position you are applying for:

How did you hear about New Challenges?

Education

High School

Name:

Location:

Graduation Date:

Degree/Area:

Trade School

Name:

Location:

Graduation Date:

Degree/Area:

College

Name:

Location:

Graduation Date:

Degree/Area:

Employment History

Begin with current or most recent employment.

Employer:

Address:

Phone:

Supervisor:

Job Title:

Work Performed:

Dates Employed:

Reason for Leaving:

Beginning Wage:

Ending Wage:


Employer:

Address:

Phone:

Supervisor:

Job Title:

Work Performed:

Dates Employed:

Reason for Leaving:

Beginning Wage:

Ending Wage:


Employer:

Address:

Phone:

Supervisor:

Job Title:

Work Performed:

Dates Employed:

Reason for Leaving:

Beginning Wage:

Ending Wage:

References

Name/relationship: Phone:

Name/relationship: Phone:

Name/relationship: Phone:

Applicant's Statement:

I understand that New Challenges, Inc. may make a thorough investigation of my entire work history and may verify all information given in my application for employment, related papers, or oral interviews. I authorize New Challenges, Inc. to request this information and I release from liability any person giving or receiving such information. I understand that falsification of data given, or other derogatory information discovered as a result of this investigation may prevent me from being hired or may subject me to immediate dismissal.

It is my understanding that this application form does not constitute an employment contract. I also understand that my employment is not for a specified or definite period of time and that I may be discharged, or I may resign, at any time, for any reason, with or without good cause and with or without agreement signed by me and a corporate officer of New Challenges, Inc.

Your name:

Date:


Applicant Background Study

Items marked with a asterisk (*) are required. All other information is optional. **Your social security number is not required by law or by DHS, but is necessary if you would like your background study to be transferable to other providers.

Current Name

First:

Middle:

Last:

Suffix:

Permanent Address

Address:

City:

State:

Zipcode:

County:

Country:

Mailing Address (if different than permanent address)

Address:

City:

State:

Zipcode:

County:

Country:

Other first names that you have used:

Other last names that you have used:

Social Security Number**:

Date of Birth:

Race:
 Asian or Pacific Islander African American Native American Caucasian Unknown/other

Gender*:
 Female Male Unknown/other

Eye Color*:

Hair Color*:

Height:
Feet: , Inches:

Weight:

US Citizen:  Yes No

Telephone Number: Secondary Phone:

Email Address:

Have you lived outside of Minnesota in the past 5 years (US states only)?  Yes No

If you have lived in another US state in the past 5 years, list addresses below:

Address:

City:

State:

Zipcode:


Address:

City:

State:

Zipcode:


Address:

City:

State:

Zipcode:

Check if you have lived in additional locations not listed above:

Minnesota Department of Human Services (DHS) Fact Sheets

Background Study Notice of Privacy Practices

Acceptable Forms of Identification for DHS Background Studies

Fingerprint and Photo Information for DHS Background Study Subjects

Affirmative Action Survey

Submission of this information is voluntary. Government agencies require periodic reports on the gender, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only.

Gender:  Female Male

Racial/ethnic heritage group:  White, not of Hispanic origin: A person having origins in Europe, North Africa or the Middle East Black, not of Hispanic origin: A person having origins in any of the Black racial groups of Africa. Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin regardless of race. Asian or Pacific Islander: A person having origins in the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes: China, Japan, Korea, the Philippine Islands, Vietnam and Samoa. Native American or Alaskan Native: A person having origins in North America and who maintain cultural identification through tribal affiliation or community recognition. Other race and or ethnicity unknown.

Position applied for (please check all the positions for which you are applying):  Program Director Program Coordinator Program Counselor RN/LPN Office Manager Office Assistant Maintenance

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