Personal Information

Employment Desired

Education

General

This page of the application is optional – feel free to scroll to the bottom of the page and click “next” if you do not wish to disclose any of this information.

Voluntary Self-Identification Affirmative Action

Our company is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Completion of information below is voluntary.

Employee Information:

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 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)

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.

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.

Employment History

List below your last four employers, starting with the last one first.

References

List below three persons not related to you, whom you have known at least one year.

PLEASE READ CAREFULLY BEFORE SIGNING

I hereby certify that the information provided on this application is accurate to the best of my knowledge and subject to verification by this company. I authorize the company, its affiliates and their representatives to investigate all information given and to secure additional job-related information if necessary I authorize an investigative report to be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors or others with whom I am acquainted, By applying, I also agree to an Internet search.

I understand and consent to an inquiry that may include information as to my character, general reputation, and personal characteristics, whichever may be applicable This information may include, but is not limited to, verification of previous employment and employment references, verification of education including requests for transcripts, credit reports, motor vehicle driving records and criminal reports, etc. I hereby release from all liability or responsibility all persons. companies, organizations or corporations furnishing such information.

I understand that any misrepresentation or omission of a material fact on my application, any other document, as well as verbal statements made, may be justification for refusal of employment, or if employed, dismissal without advance notice.

In the event I am employed, I understand that all employees are subject to termination at the discretion of the company. If, in the event I choose to voluntarily terminate my employment, I am free to do so at any time, and, if I choose to give proper notice of termination, the company may either permit me to continue my employment during the notice period or may accept my resignation immediately.

I understand that in the event I am employed by the company, my compensation, hours of employment and all other terms and conditions of employment are subject to modification or change by the company at the company’s discretion.

I authorize the company to supply my employment record, in whole or in part, and in confidence, to any prospective employer, government agency, or other party, with a legal and/or proper interest.

In the event of my employment, I will comply with all rules and regulations as set forth in the company’s policy manual or other communications distributed to all employees.

I understand that, in the event I am employed by the company, I will be required to furnish proof of identity and legal authorization to work in the United States.

I authorize the company to supply my employment record, in whole or in part, and in confidence, to any prospective employer, government agency, or other party, with a legal and/or proper interest.

I also understand that my employment is conditional upon my satisfactorily passing a drug screening, if one is requested, to be given by a physician, clinic or other health care provider selected by the company.

I understand that completion of this form does not guarantee me status as an applicant or any consideration for employment unless I meet all stated minimum qualifications required of the position for which I am asking to be considered.

I have read the above statements and accept them as conditions of employment with the company.