Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5083 or 1-800-342-5354 www.dli.mn.gov R-20 Qualified Rehabilitation Consultant Intern Application (check one) Initial registration Renewal Reinstatement Print in ink or type Applicant's name Telephone number Employer Employer's address City QRC intern supervisor's name Work email address Telephone number Home address (where certified mail can be delivered) Public mailing address (if different from home address) City QRC number State ZIP code State ZIP code QRC expiration date Firm number Applicant's Social Security number THE FOLLOWING INFORMATION IS REQUIRED FOR INITIAL REGISTRATION, RENEWAL AND REINSTATEMENT APPLICATIONS 1. Do you have a current professional license, certificate or registration? If yes, which certification? Certified Rehabilitation Counselor (CRC) Certified Disability Management Specialist (CDMS) Other _____________________________________ Attach a current copy of each license, certification or registration. 2. Do you want to be identified on the department's website as a QRC intern who is proficient in any language other than English, including sign language? Yes No If yes, name language(s). 3. Have you applied for registration as a QRC intern or a registered rehabilitation vendor in Minnesota in the past? Yes No If yes, give date(s) Yes No Payment information: Enclose a check or money order for $100 payable to the "Minnesota Department of Labor and Industry". Send all application documents and fees to the department's Financial Services unit at the above address. FOR INITIAL REGISTRATION APPLICATIONS ONLY Educational data: Submit official transcripts of all pertinent post-secondary education Plan of supervision: A plan of supervision addressing all of the requirements of Minnesota Rules 5220.1400, subp. 3a, must be attached to this application. Employment history MN R-20 (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com Describe in detail your work history beginning with your current or most recent job and attach your resume and/or additional sheet(s) as necessary. List or attach any other information that may be pertinent to registration (such as honors, peer recognition, volunteer work). Employer name Address City Duties State ZIP code Phone number Dates (from and to) Job title Immediate supervisor's name Employer name Address City Duties State ZIP code Phone number Dates (from and to) Job title Immediate supervisor's name FOR RENEWAL APPLICATIONS ONLY I request approval of completion of internship. All documentation required by Minn. Rules 5220.1400, subp. 4, is attached. Continuing education: Documentation of 20 contact hours each year is required if a QRC intern does not have CRC or CDMS certification. Continuing education units must be obtained in the 12-month period immediately preceding the date on which registration renewal forms are due (Minn. Rules 5220.1500, subp. 3a). List continuing education units below (attach additional sheet, if necessary). Attach legible certificates of attendance bearing the name of the participant that are signed and dated by the sponsoring institution or organization. Course title Sponsor Date Hours MN R-20 (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com FOR REINSTATEMENT APPLICATIONS ONLY If you are applying for reinstatement of registration, you must provide verification of all of the following (Minn. Rules 5220.1500, subp. 4): A. current certification as required by Minn. Rules 5220.1400; B. attendance at the most recent update session or a recording of that session; C. documentation of continuing education requirements as provided by Minn. Rules 5220.1500, subp. 3a; D. payment of any applicable late fees if the applicant failed to notify the commissioner that registration renewal was not being sought; and E. if the applicant has been on inactive status or has failed to renew registration for more than two years, the applicant must also complete an orientation training session before acceptance is final. Note: A plan of supervision addressing all of the requirements of Minn. Rules 5220.1400, subp. 3a, must be attached to this application. I authorize the Workers' Compensation Division, Department of Labor and Industry, to make any appropriate investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection of this application or denial of registration. I agree to be bound by all statutes, rules and orders as established by the commissioner and realize that violations may result in the denial or revocation of registration. I understand that Minn. Rules 5220.1250 prohibits any ownership or financial relationship of any kind between any registered rehabilitation vendor and qualified rehabilitation consultant firm, qualified rehabilitation consultant or qualified rehabilitation consultant intern. I agree to notify the department immediately of any change in my employment status (Minn. Rules 5220.1400, subp. 5). If there is a change in my employment status, I will notify all parties to the case on which I am the assigned QRC intern as to whom the reassignment will be made (Minn. Rules 5220.1801, subp. 9K(2)). I certify that I am a full-time resident of Minnesota or I live no more than 100 miles by road from the Minnesota border (Minn. Rules 5220.1400, subp. 5). Notice: The information you as an individual provide in this application will be used by Department of Labor and Industry (department) staff members who require the information to determine if you meet the department's registration/renewal requirements. Minnesota Statutes § 270C.72, subd. 4, requires you to provide your Social Security number on this application. The other information is being requested for purposes of processing your application. With the exception of your Social Security number, you are not legally required to supply the data requested on this application. However, failure to provide the requested information may delay the processing of your application or result in the denial of the same. The application data will be made part of the department's file for your registration/renewal. Except for your name and the address you designated to receive correspondence from the department, the information you provide on this application is private data while the application is pending. Once you are registered, the application data may become public except for