Name *

First Name

Last Name

Will you complete the voluntary, self-identification form? *

Completion of this form is voluntary. The information will be kept confidential; It will not be filed with your application. Refusal to provide it will not deny you further employment considerations.

Yes

No

Race/Ethnicity - Persons Having Origins

WHITE: Person of Indo-European descent

BLACK: Person of African, Jamaican, Trinidadian or West Indian descent.

ASIAN: Person of Japanese, Chinese, Korean or Pacific Islander descent.

AMERICAN INDIAN: Person descended from original North American, and who maintain cultural identification through tribal affiliation

HISPANIC: Person of Mexican, Puerto Rican, Cuban, South American, or other Spanish descent.

Gender

Male

Female

Disability Status

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: • Autism • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Blind or low vision • Cancer • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or hard of hearing • Depression or anxiety • Diabetes • Epilepsy • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Intellectual disability • Missing limbs or partially missing limbs • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Yes, I have a disability or have a history/record of having a disability

No, I do not have a disability or have a history/record of having a disability

I do not wish to answer

Veteran Status

A "disabled veteran" is one of the following: o 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 o 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.

I identify as one or more of the classifications of protected veterans listed above. (V)

I am not a protected veteran. (N)

I do not wish to answer.