Application for Employment - Lighthouse Beginnings

Name

First

Last

Social Security Number

Date of Birth

Phone

Address

City

State

Zip Code

Email

Availability

Position Applying For

1. Are you Certified in the State of MN as a CPRS?

Yes

No (Skip to #5)

2. What is your PRSS Certification date?

3. How long have you been a Peer?

4. Where have you been a Peer?

What is your lived experience?

Substance-use disorder

Mental Health

Criminal Justice System

Most Recent Employer

Phone

Position/Dates

Reason for leaving

Previous Employer

Phone

Position/Dates

Reason for leaving

Previous Employer

Phone

Position/Dates

Reason for leaving

School/Training

Location

Time Attended

Certification

School/Training

Location

Time Attended

Certification

References (Name)

Relationship & Length of time known

Phone Number

References (Name)

Relationship & Length of time known

Phone Number