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Maximum number of characters for this text box is 255.
PLEASE READ BEFORE COMPLETING THIS SURVEY
Employees are treated during employment without regard to race, color, religion, sex, national origin, age, veteran status, disability, or any other protected status.
As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Acton responsibilities where they apply.
The purpose for this Data Survey is to comply with government record keeping, reporting, and other legal requirements. This data is for statistical analysis with respect to the success of the affirmative action program. Periodic reports are made to the government on this information. The completion of this data survey is optional. If you choose to volunteer the requested information, please note that all Data Surveys are kept in a confidential file and are not part of your Application for Employment or personnel file.
SUBMISSION OF THIS INFORMATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.
APPLICANT SURVEY * Required but you may delcine
American Indian/Alaskan Native
Native Hawaiian/ Pacific Islander
Two or more races
Decline to furnish ethnic origin
I am not a protected veteran
I choose not to provide this information
I identify as one or more of the classifications of protected veterans listed in this survey
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
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.1 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 or any punishment because you did not identity 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, of 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)
Please check one of the boxes below: * Required but you may delcine
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON'T HAVE A DISABILITY
I DON'T WISH TO ANSWER
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.
1Section 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.
Veteran Category Definitions:
Disabled Veteran – (1) 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 (2) A person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran – 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.
Armed Forces Service Medal Veteran – Any 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.
Active duty wartime or campaign badge veteran – 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.
If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job. The information you submit will be kept confidential, except that (1) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations: (2) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment: and (3)Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
I understand that this Driver Internet Reference Form is a preliminary application and that if requested I will complete an Alan Ritchey, Inc. Driver Application for Employment. I further understand this Reference Form will be reviewed carefully, but its receipt does not imply that I will be employed. In addition, I understand that Alan Ritchey Inc. participates in E-Verify to determine the eligibility of their employees to work in the United States. For more information on E-Verify, please go to http://www.dhs.gov/files/programs/gc_1185221678150.shtm.
I certify that I personally completed this application and that all the information is true and correct. By submitting this application I authorize the release of all alcohol and controlled substance testing results pursuant to 382.2413 of the Federal Motors Carriers Safety Regulations and release this company from any and all liability as a result of providing the above information.