Voluntary Affirmative Action Questionnaire:

Voluntary Veteran Self-Identification Form:

This employer may be a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 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.

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.ⁱ 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.

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.

Disabilities include, but are not limited to:

Blindness	Deafness	Cancer	Diabetes
Autism	Cerebral palsy	HIV/AIDS	Schizophrenia
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)
Epilepsy	Muscular dystrophy

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.

ⁱ 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.

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.

Terms and Conditions:

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal, and I agree to hold my employer harmless in the event of my dismissal based thereon. I authorize investigation of all statements contained herein and to do background checks to give you and all information concerning my previous employment and any pertinent information they may have, confidential or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I realize that under certain legal provisions, pre-employment drug testing could be a condition of my employment. I also acknowledge that the employer may require drug testing at a subsequent time providing that proper advance notice of testing is provided. I also recognize that I could be offered employment subject to appropriate medical examination and that such a report could nullify my ultimate employment by this employer. I agree to submit to physical examination if required. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the method of payment of my wages and salary, be terminated at any time without prior notice. If employment is obtained under this application, I will comply with all the rules and policies of my employer." AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER This employer does not discriminate in hiring or employment on the basis of age, race, color, sex, religion, national origin, disability, military or veteran status

I understand and accept the terms described above.