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Lao Democratic Republic
Papua New Guinea
Saint Vincent Grenadines
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Have you reached your 18th Birthday?
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Were you previously employed by Heartland Alliance or any of its affiliates?
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Were you laid off from Heartland within the last 12 months?
Were you laid off from Heartland within the last 12 months?:
Are you currently authorized to work in the U.S. for any employer?
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Will you now or in the future require visa sponsorship to work for us?
Will you now or in the future require visa sponsorship to work for us?:
Yes, I understand that Heartland Alliance requires all employees to be fully vaccinated against Covid-19 or to have an approved accommodation.
Do you have any relatives or friends who are currently employed with Heartland Alliance or a Heartland Alliance Subsidiary?
Do you hold professional licensure or certification? If yes, please list type of license or certification and provide number.
Do you hold professional licensure or certification?:
If yes, please list type of license or certification and provide number.:
Are you bilingual/multilingual? If yes, please list languages and level of proficiency.
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Resume & Attachments
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You can use the text area for a cover letter and any supplementary information you would like to provide about your career goals, availability, best times to contact you, etc.
How did you hear about us?
Adler School of Professional Psychology
Chicago Latino Network
Heartland Careers Website
HLPA (Hispanic/Latino Professionals Association)
IL Counseling Asso
IL Job Link
Job Fair (Please specify event)
Other (Please Specify)
The Chicago School of Professional Psychology
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Equal Opportunity Questionnaire
As an equal opportunity employer, we do not discriminate due to actual or perceived race, religion, creed, color, national origin, age, gender, gender identity, sexual orientation, marital status, veteran or military status (including unfavorable discharge from the military), disability, work authorization status, citizenship status, order of protection status, or arrest or conviction history. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.
Choose Not to Disclose
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
Voluntary Self-Identification of Veteran Status
This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment:
recently separated Veterans
active duty wartime or campaign badge Veterans
Armed Forces service medal Veterans
These classifications are defined as follows:
A "disabled Veteran" is one of the following:
A Veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected disability.
A "recently separated Veteran" means any Veteran during the three-year period beginning on the date of such Veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.
An "active duty wartime or campaign badge Veteran" means a Veteran who served on active duty in the U.S. military, ground, naval, or air services during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed Forces service medal Veteran" means a Veteran who, while service on active duty in the U.S, military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. If you believe you belong to any of the categories of protected Veterans listed above, please indicate by making the appropriate selection below. As a government contractor subject to VEVRAA, we request this information to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
I identify as a protected Veteran
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Voluntary Self-Identification of Disability
Candidate Individual with disabilities:
Voluntary Self-Identification of Disability
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Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do you know if you have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
• Autism • Deaf or hard of hearing • Missing limbs or partially missing limbs • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Depression or anxiety • Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS) • Blind or low vision • Diabetes • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression • Cancer • Epilepsy • Cardiovascular or heart disease • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Celiac disease • Intellectual disability • Cerebral palsy Please Select one of the options below :
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don't Have A Disability, Or A History/Record Of Having A Disability
I Don't Wish To Answer
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
For Employer Use Only Employers may modify this section of the form as needed for recordkeeping purposes. For example:
Job Title: _______________
Date of Hire: _______________
Attestation and Electronic Signature
I certify the answers given herein are true and complete to the best of my knowledge, and I authorize the investigation of all statements contained within this employment application that may be necessary in arriving at an employment decision. I further understand that, in the event of my employment by the Agency, any false or misleading information given in my application or interview(s) may result in discharge. I also understand that if employed by the Agency, I will be required to abide by all Agency rules and regulations.
I understand this application and any subsequent offer of employment I may receive from the Agency does not, and is not intended to, create a contract of employment or any contractual rights in favor of the Agency or me beyond those existing in an “at will” employment relationship unless provided otherwise by an applicable collective bargaining agreement. I understand that any employment relationship which may arise between the Agency and me will be an “at will relationship,” which means the Agency reserves the right to change, modify, suspend, revoke, or terminate my employment at any time, with or without reason, and with or without notice, and that I likewise have the right to terminate my employment with the Agency at any time, with or without notice. I further understand no representative of the Agency, other than the President/Chief Executive Officer, has any authority to enter into any agreement for employment for any specified time, or to make any agreement contrary to the foregoing, and any such general or specific commitments must be in writing, in a document executed by the President/ Chief Executive Officer and me.
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