"*" indicates required fields Step 1 of 6 16% HiddenDate MM slash DD slash YYYY PositionPosition You're Applying For*Select a Position HereAccess ClinicianAccess CoordinatorAccess SupervisorADC InternADC SupervisorAdministrative CoordinatorAlcohol and Drug Counselor – PrimaryCertified Peer Recovery SpecialistCertified Therapeutic Recreation SpecialistCo-Occurring InternCD/SUD TechnicianDietitian NutritionistHealth Promotion Services ManagerHousing ManagerLicensed Program SupervisorLicensed Program ManagerMental Health InternOther/CustomOccupational TherapistProgram SupervisorProgram ManagerRegistered NurseTreatment CoordinatorTreatment DirectorOther Position Applicant InformationResume Upload*Max. file size: 50 MB.Applicant Name* First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone Number*Have you ever worked Horowitz Health or any of it's related entities?* Yes No Start & End Dates* Are you legally able to work in the United States?* Yes No Date Available to Start* MM slash DD slash YYYY Position Applied for* Employment Type* Full-Time Part-Time Seasonal Desired PayPer Hour Salary If driving is required for role, are you okay with driving?* YES NO Do you have a valid driver's license?* YES NO Do you have valid vehicle insurance?* YES NO High SchoolSchool Name* Address Did you graduate from High School/GED?* Yes No Date Attended From MM slash DD slash YYYY Date Attended To MM slash DD slash YYYY Degree Earned Diploma or GED?Did you attend trade school, college or university?* Yes No College/UniversityName Address Did you graduate from college or university? Yes No Date Attended From MM slash DD slash YYYY Date Attended To MM slash DD slash YYYY Degree Earned Do you have other education to report? Yes No Other SchoolSchool Name Address Did you graduate? Yes No Date Attended From MM slash DD slash YYYY Date Attended To MM slash DD slash YYYY Degree Earned Current EmployerPlease provide information for your previous three employers.Most Recent or Current Employer* Position Title* Phone*Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl 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Date* Duties/Responsibilities Reason for leaving* Starting Pay*Per Hour Salary Ending Pay*Per Hour Salary Do you have additional employment to report?* Yes No Additional EmploymentCompany 2 Position Title PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment Start Date Employment End Date Duties/Responsibilities Reason for leaving Starting PayPer Hour Salary Ending PayPer Hour Salary Company 3 Position Title PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment Start Date Employment End Date Duties/Responsibilities Reason for leaving Starting PayPer Hour Salary Ending PayPer Hour Salary References First Reference Name Company Job Title Relationship eMail Address Phone Number Second Reference Name Company Job Title Relationship eMail Address Phone Number Third Reference Name Company Job Title Relationship eMail Address Phone Number Military ServiceAre you a veteran? Yes No Branch* Rank at Discharge Service Date From: Service Date To: Discharge TypeSelect Discharge TypeHonorable DischargeGeneral Discharge Under Honorable ConditionsOther Than Honorable (OTH) DischargeEntry-level SeparationMedical SeparationSeparation for Convenience of the GovernmentBad Conduct Discharge (issued by special court-martial or general court-martial)Dishonorable DischargeExplain any discharge other than honorable: Applicant Statement, Consent & SignatureIf asked, are you willing to submit to a criminal background study?* Yes No Please realize this may be a condition of employment depending on the agency and position you’re applying for.Applicant Statement & Consent* I agree to the statement below and consent to the application terms and requirements.I certify that the information contained in this application is correct and complete to the best of my knowledge. I understand that any false or misleading information given in my application, resume, or interview(s) may result in The Company’s determination to not offer employment or, in the event of employment it may result in discharge. I understand that all offers of employment are conditional upon satisfactory background checks and reference checks. If required, I consent to The Company submitting any background checks applicable for my employment and to contact my references, for the purpose of verifying employment history and information offered in interviews and other job-related information as necessary. I will hold The Company, background check entities, and all references contacted harmless for their actions related to the background check results and/or to the verification. I agree to abide by all The Company policies and regulations, if I am hired. I understand that my employment will be for an indefinite term and that I may terminate the employment relationship and The Company also may terminate the relationship, for any reason and without prior notification. Any modification of the terms of my employment relationship with The Company must be in writing and signed by The Company.Applicant Signature*