Application Data Form

Detach from Employment Application and Submit Separately

Notice to Applicants - Completion of this form is volunatry

We are an Affirmative Action, Equal Opportunity Employer. Our employment decisions are made without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, citizenship, age, diability, marital status, or any other legally protected status. The purpose of the Applicant Data Form is to comply with federal government record-keeping and reporting requirements. Periodic reports are made to the government on the following information. The data you provide on this form will be kept confidential and used solely for statistical purposes. This form is processed and maintained separately from your employment application and is not used in the interview or selection process. Completion of this form is optional and voluntary.

Voluntary Self-Identification of Ethnicity, Race and Gender

5. Race/Ethnic Code: (Please Select One)


Thanks for your Assistance

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:
(1) disabled veterans;
(2) recently separated veterans;
(3) active duty wartime or campaign badge veterans; and
(4) 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 service 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 serving 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.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1–866–4–USA–DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA


Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I 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

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular
    dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or
    partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental
    retardation)

Voluntary Self-Identification of Disability

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

____________________________

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp

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