Employment Supplement - Independent Living, Inc.

Submission of this form is Voluntary.

Independent Living, Inc. and independent Health Care, Inc. have adopted an Affirmative Action Plan in compliance with State and Federal Law and City of Madison policies and ordinances. The disclosure of the following information is voluntary and allows us to meet federal, state and city government reporting requirements. The sheet will be removed from your application and the data will be treated as confidential and will not be used in making employment decisions. Refusal to provide this information will not subject you to adverse treatment.

Name: *

Please enter your name

Position(s) applied for: *

Please enter what position(s) you are applying.

Date of Birth:

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Veteran Status

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If "Other", please specify

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Racial and/or Ethnic Heritage: *

White, not Hispanic/Latino origin
A person having origins in any of the original peoples of Europe, the Middle East or North Africa

Black or African American, not Hispanic/Latino origin
A person having origins in any of the Black racial groups of Africa

Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race

American Indian or Native Alaskan, not Hispanic/Latino origin
A person having origins in any of the original peoples of North and South America, including Central American, who maintain tribal affiliation or community attachment

Asian, not Hispanic/Latino origin
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam

Native Hawaiian or Other Pacific Islander, not Hispanic/Latino origin
A person having origins in any of the original peoples of Hawaii, Guana, Samoa, or other Pacific Islands

Two or more races, not Hispanic/Latino origin
All persons who identifies with more than one of the above races
Other
A person not fitting into any of the above categories

Please make a racial / ethnic heritage selection

(please specify):

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Gender: *

MaleFemale

Please select a gender

Do you have a disability? *

YesNo

Please enter disability status

Independent Living, Inc. and Independent Health Care. Inc. consider a person with a disability anyone who meets the definition under either the Americans with Disabilities Act of the Wisconsin Fair Employment Act.

Please enter the security code:

Please enter the security code.

Submission of this form is Voluntary.
Independent Living, Inc. and independent Health Care, Inc. have adopted an Affirmative Action Plan in compliance with State and Federal Law and City of Madison policies and ordinances. The disclosure of the following information is voluntary and allows us to meet federal, state and city government reporting requirements. The sheet will be removed from your application and the data will be treated as confidential and will not be used in making employment decisions. Refusal to provide this information will not subject you to adverse treatment.
Fields marked with an asterisk (*) are required.
Name: *	Please enter your name
Position(s) applied for: *	Please enter what position(s) you are applying.
Date of Birth:	Invalid Input
Veteran Status	Invalid Input
If "Other", please specify	Invalid Input
Racial and/or Ethnic Heritage: *	White, not Hispanic/Latino origin A person having origins in any of the original peoples of Europe, the Middle East or North Africa Black or African American, not Hispanic/Latino origin A person having origins in any of the Black racial groups of Africa Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race American Indian or Native Alaskan, not Hispanic/Latino origin A person having origins in any of the original peoples of North and South America, including Central American, who maintain tribal affiliation or community attachment Asian, not Hispanic/Latino origin A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam Native Hawaiian or Other Pacific Islander, not Hispanic/Latino origin A person having origins in any of the original peoples of Hawaii, Guana, Samoa, or other Pacific Islands Two or more races, not Hispanic/Latino origin All persons who identifies with more than one of the above races Other A person not fitting into any of the above categories Please make a racial / ethnic heritage selection
(please specify):	Invalid Input
Gender: *	MaleFemale Please select a gender
Do you have a disability? *	YesNo Please enter disability status
Independent Living, Inc. and Independent Health Care. Inc. consider a person with a disability anyone who meets the definition under either the Americans with Disabilities Act of the Wisconsin Fair Employment Act.
Please enter the security code:	Please enter the security code.