Employment Application Self-Identification Form
The following information is being requested for Government reporting purposes only. The information that you supply will not be used in our selection decision. Your submission of this information is optional. Failure to provide the information will not be used against you.
- (i) Disabled Veterans
- (ii) Veterans who served on active duty in the Armed forces during war on in a campaign or expedition for which a campaign badge has been authorized.
- (iii) Veterans who, while serving on active duty in the Armed Forces, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985 (61Fed. Reg. 1209)
- (iv) Recently separated veterans. Recently separated is up to three years.
Veteran of the Vietnam Era
Person who served on active duty for a period of more than 180 days, and was discharged or released there from with other than dishonorable discharge, if any part of such active duty occurred in the Republic of Vietnam between 2/28/61, and 5/7/75, or between 8/5/64 and 5/7/75 in all other cases.
Voluntary Self-Identification of Disability
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.
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:
- Cerebral Palsy
- 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)
I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time. If hired, I agree to conform to the Company’s rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either expressed or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company’s option.
I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age disability, or any other protected status under applicable federal, state or local law. This Company takes all harassment complaints seriously and investigates each one promptly and thoroughly.
I understand that this employer does not lawfully discriminate in employment and no question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.