Fill and Sign the Applicant Voluntary Self Identification Form Section I

SELF-IDENTIFICATION FORM This is an invitation for voluntary inclusion in the affirmative action program at [Name of Company] for individuals with disabilities, special disabled veterans, and veterans of the Vietnam era.It is the policy of [Name of Company] to recruit, select, and employ qualified individuals with disabilities, special disabled veterans, and veterans of the Vietnam era. The company is a government contractor subject to Section 503 of the Rehabilitation Act of 1973 and Section 4212 of the Vietnam Era Veterans’ Readjustment Assistance Act of 1974.In accordance with these laws, [Name of Company] is committed to affirmative action programs that employ and advance in employment qualified individuals with disabilities, special disabled veterans, and veterans of the Vietnam era. [Name of Company] will, where appropriate, consider reasonable accommodations for qualified individuals with disabilities.If you are an individual with a disability, a special disabled veteran, or a veteran of the Vietnam era and would like to be considered under our affirmative action programs, please check the applicable portion below. Appropriate definitions of these terms are provided for your convenience.If you are an individual with a disability or special disabled veteran, you may choose to tell us about (1) any special methods, skills, and procedures that qualify you for positions within the company so that you can be considered for any positions of that kind, and (2) the reasonable accommodations that we could make that would enable you to perform the job properly and safely, including special equipment or other accommodations.Note: While we invite you to offer this information, it is strictly voluntary. Refusal to provide this information will not subject any individual to negative consequences by the Company. Please also note that if you do not self-identify at this time, you may still volunteer this information at a later date, without subjecting yourself to any adverse treatment.We will keep your information in strict confidence, except that (a) necessary management and supervisory personnel may be informed to ensure proper placement and to provide reasonable job accommodations, (b) first aid and safety personnel may be informed to the extent appropriate, if the condition might require emergency treatment, and (c) government officials investigating affirmative action program compliance may be informed under the above cited laws and the Americans with Disabilities Act.To be included in our affirmative action program, please check the appropriate boxes and provide your name in order to be identified as: An “individual with a disability” is a person who (1) has a physical or mental impairment that substantially limits one or more of his/her major life activities; (2) has a record of such impairment; or (3) is regarded as having such as impairment. A “special disabled veteran” is a veteran who is entitled to disability compensation under laws administered by the Department of Veterans Affairs for a disability (1) rated at 30% or more, or (2) rated at 10-20% in the case of a veteran who has been determined under Section 1506 to have a serious employment disability or a person who was discharged or released from active duty because of a service- oriented disability. A “veteran of the Vietnam era” is a person who served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975 and who (1) was discharged or released therefrom with other than a dishonorable discharge, or (2) was discharged or released from active duty for a service-connected disability. Name: Location: Department: Employee No.: Date: