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The Minnesota R 20 form serves as a crucial application for individuals seeking approval and registration as Qualified Rehabilitation Consultant Interns. This form is managed by the Minnesota Department of Labor and Industry and requires applicants to provide a range of personal and professional information. Key sections of the form include personal data, education history, and employment details. Applicants must specify their professional licensure or certifications, if any, and include supporting documents such as transcripts and proof of supervision by an established Qualified Rehabilitation Consultant. A fee of $110 is required to process the application, which includes a surcharge mandated by state law. Furthermore, the form prompts applicants to disclose language skills and any prior applications for registration in Minnesota. Completing the R 20 form accurately is essential, as any omissions or misrepresentations can lead to rejection or revocation of registration. The form also emphasizes the importance of notifying the Workers’ Compensation Division of any changes in employment status, ensuring that all parties involved are kept informed throughout the process.
Form Example
Minnesota Department of Labor and Industry Financial Services
443 Lafayette Road North St. Paul, MN 55155 (651)
Please PRINT or TYPE
PERSONAL DATA
Application for Approval and Registration
Qualified Rehabilitation Consultant Intern
NAME (last, first, middle) |
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ADDRESS (residence) |
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PROSPECTIVE EMPLOYER |
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CITY |
STATE ZIP CODE |
EMPLOYER ADDRESS (Your mailing address) |
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HOME PHONE NUMBER |
BUSINESS PHONE NUMBER |
CITY |
STATE ZIP CODE |
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1. Do you hold a professional licensure, certification or registration?
If yes, which certification? |
CRC |
CDMS Other: |
Please attach a copy of any license/certification/registration.
Yes
No
2.Name of Qualified Rehabilitation Consultant (QRC) under whose supervision you will work.
3.Enclose a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry. (This includes the 10% surcharge pursuant to 2009 Laws, Chapter 101, Article 2, Section 59.) Send all application documents and fees to the Department’s Financial Services Section at the above address.
4.Do you speak or write any foreign language? If yes, name language and number of years.
Yes
No
5. Are you able to communicate with the deaf in sign language?
Yes
No
6. 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) |
EDUCATION DATA |
ATTACH OFFICIAL TRANSCRIPTS OF ALL PERTINENT POSTSECONDARY EDUCATION |
NAME OF SCHOOL
CITY/STATE
DATES ATTENDED
FROMTO
month/year month/year
DEGREE OR HIGHEST GRADE COMPLETED
Attach a list of continuing education within the past 2 months which pertains to this registration.
NOTE TO QRC SUPERVISOR: Please see Minn. Rules 5220.1400, subp. 3a and attach a plan of supervision addressing all of the requirements of this subpart.
MN |
over |
EMPLOYMENT HISTORY
Describe in DETAIL your work history beginning with your current or most recent job. Attach an additional sheet, if necessary.
EMPLOYER NAME |
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PHONE NUMBER |
IMMEDIATE SUPERVISOR NAME |
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ADDRESS |
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DATES (from and to) |
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CITY |
STATE |
ZIP CODE |
JOB TITLE |
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Duties: |
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EMPLOYER NAME |
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PHONE NUMBER |
IMMEDIATE SUPERVISOR NAME |
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ADDRESS |
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DATES (from and to) |
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CITY |
STATE |
ZIP CODE |
JOB TITLE |
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Duties: |
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List or attach any other information that may be pertinent to registration (i.e., honors, peer recognition, etc.)
I authorize the Workers’ Compensation Division, Department of Labor and Industry to make any investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection or revocation of registration.
I hereby agree to be bound by all statutes, rules and orders and realize that violations may result in revocation of registration.
Subject to approval of this application I agree to notify the Workers’ Compensation Division, Department of Labor and Industry of any change in my employment status. Given a change in my employment status I will accept the responsibility to notify all parties to the case on which I am the assigned Qualified Rehabilitation Consultant Intern as to whom the reassignment will be made, subject to approval of the Commissioner of Labor and Industry.
I CERTIFY THAT I AM A
APPLICANT SIGNATURE
DATE
NOTARY FOR APPLICANT
MY COMMISSION EXPIRES
I hereby agree to provide the supervision outlined on the attached sheet and as provided by Minn. Rules 5220.1400, subp. 3a.
SUPERVISOR SIGNATURE
DATE
NOTARY FOR SUPERVISOR
MY COMMISSION EXPIRES
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651)
Form Specifications
| Fact Name | Details |
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| Purpose | The Minnesota R-20 form is used to apply for approval and registration as a Qualified Rehabilitation Consultant Intern. |
| Governing Laws | This form is governed by Minnesota Rules 5220.1400, which outlines the requirements for registration and supervision of Qualified Rehabilitation Consultants. |
| Application Fee | An application fee of $110.00 is required, which includes a 10% surcharge as per 2009 Laws, Chapter 101, Article 2, Section 59. |
| Residency Requirement | Applicants must certify that they are full-time residents of Minnesota or live within 100 miles of the Minnesota border. |
| Language Proficiency | The form inquires about the applicant's ability to communicate in foreign languages and with the deaf in sign language. |
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