YesNo
YesNo
YesNo
YesNo
YesNo

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied will be taken into account.


YesNo

Employment History

List all previous employers, starting with your present or most recent position (last 10 years is sufficient) below.

Employer 1

DATES OF EMPLOYMENT:


Employer 2

DATES OF EMPLOYMENT:


Employer 3

DATES OF EMPLOYMENT:

Education


Skills and Qualifications

List three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references are who are not related to you.

REFERENCE #1

REFERENCE #2

REFERENCE #3

Affirmative Action Information -- Voluntary

Thank you for your interest in employment with our Company. The following questions about your race and gender are included only because of government regulations, and you do not have to answer them. As an Equal Opportunity Employer, the Company does not use this information in its employment decisions, so whether or not you return this form has no effect on your application. Submitting this information is purely voluntary. If you choose to submit it, it will be kept confidential to the extent provided by law. Leaving this section blank is treated as deciding not to disclose the information, which is your right.

FemaleMaleRather not say
Hispanic/LatinoWhiteBlack/African AmericanAsianNative Hawaiian/Other Pacific IslanderAmerican Indian/Alaska Native
NonePre-Vietnam EraVietnam EraPost-Vietnam Era
Yes, I have a disability (or previously had a disability)No, I do not have a disabilityI do not wish to answer

UPLOAD RESUME:

OPTIONAL - APPLICANTS MAY ATTACH A RESUME FILE IN EITHER .PDF OR .DOC

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017

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 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)

I agree that I have read and understand the above paragraph, and agree to the terms and conditions outlined above.