Online Application for Employment

Job 1 Name of Present or Previous Employer *

I certify that I have read, full understand, and accept all terms of the above applicant statement *

Please check ONE of the boxes below for disability

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DO NOT HAVE A DISABILITY

I DO NOT WISH TO ANSWER

Voluntary Self-Identification of Disability

Do you have any relatives currently employed with any Horizon Health Network company? If so, list the month and year. *

May we contact your present employer?

Yes

No

Are you at least 18 years of age? *

Yes

No

Preferred number of hours to work *

Days and Times available to work *

Home Phone:

INVITATION TO SELF-IDENTIFY PLEASE ANSWER THE FOLLOWING QUESTIONS Please indicate whether you identify as one (or more) of the following protected veteran categories by checking the appropriate box or boxes below.

Disabled Veteran:

Please read and acknowledge in the below field that you understand and agree by Typing your name.

Special Skills

Full Name: *

Info

Are you prevented from lawfully becoming employed in this country because of VISA or Immigration? *

Yes

No

Position Desired:

Present Member of National Guard or Reserves?

Yes

No

Have you worked in the healthcare field before?

Yes

No

List all education institutions you have attended

New Hire Voluntary Self-Identification Form - Completion of this sheet is VOLUNTARY and is not a requirement for employment

Hispanic or Latino

No Hispanic or Latino

American Indian or Alaska Native – A person having origins in any of the original peoples of North America, Central America and South America.

White – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East

Black or African America – A person having origins in any of the original people or racial groups of Africa.

Native Hawaiian or Pacific Islander – A person having origins is any of the original peoples of Hawaii, Guam, Samoar, or the Pacific Islands.

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Vietnam, Thailand, or the Philippines.

Two or More Races – Person who identify with more than one of the above races.

Do Not Want To Disclose

Disability Acknowledgement

Additional Comments

Phone Carrier:

Job 2 Name of Previous Employer *

U.S Military Service and Rank, if applicable

SSN: *

Email: *

Check here to receive email updates

Are you Employed Now?

Yes

No

Special Training

Date You're available for work

In addition to our affirmative action obligations, we value all forms of military service. If you are not a protected veteran as described above but would like to disclose your status as a member of the military, you may do so below. Are you currently serving, or have you served, in the Armed Forces of the United States of America (including the Reserves and National Guard)?

Yes

No

I Prefer Not to Answer

Address: *

Wage Desired:

Licenses and Certifications *

Reasonable Accommodation Notice

Job 3 Name of Previous Employer *

Cell Phone: *

CPR Certified? *

Yes

No

Activities: Professional, Civic, Athletic, Etc.

Post-Offer Invitation to Self-Identify Protected Veteran Status

List 3 References, non-family members, whom you have know at least one year. Include name, email, phone, and years known *

Have you previously been employed with any Horizon Health Network company? If so, list the month and year. *

Do you have any relatives currently employed with any Horizon Health Network company? *

First Aid Certification? *

Yes

No

Horizon Health Network, LLC

Mantoux Current? *

Yes

No