Crescent Cove Staff Background Check Application

The following form requires personal information needed for Crescent Cove to complete a required background check through the State of Minnesota's required NetStudy 2.0. Should you have questions, please contact our HR Generalist at 952.426.4711 x2.

Personal information needed for background check

First Name:
Middle Name (if none, write none):
Last Name:
Suffix:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Country:
Date Of Birth:
Race:
Sex:
Eye Color:
Hair Color:
Social Security Number:
Height:
Weight:
US Citizen:
State of Birth:
Phone:
Phone Type:
Secondary Phone:
Secondary Phone Type:
Email:
Prior Names or Aliases, including maiden names, married names, name changes:
Have you lived in any other states within the U.S. within the past 5 years? If yes, please list the state and the years you lived there.:
Identification to Verify Identity (for background check): Type of Document:
Issuing State/Authority of Type of Document:
Document Number (license #, etc):
Expiration Date:

Employee Information

Employer (If retired or none, please note):
Emergency Contact Name:
Emergency Contact Cell Number:
Please summarize any special skills or qualifications you have acquired from employment and/or volunteer work:
Reference Name and Contact Number:
Relationship to Reference:

Employee Agreements

I understand and agree that submitting this form does not automatically register me as a staff, and that there are qualifications and training I must meet, including accepting established staff policies and procedures before I begin staffing:
I authorize Crescent Cove to use the information provided to run a NetStudy 2.0 Background check, required by the State of Minnesota, and to contact listed references to verify information. I release my reference from liability for providing information:
I understand that if I am accepted as a staff, any false statements, omissions, or other misrepresentations made by me on this application may result in immediate dismissal:
By submitting this form, I attest that the information I have provided is true and accurate: