Job Application Follow Up First Name *Last Name *Have you ever been convicted of a crime (other than a minor traffic violation) or do you have criminal charges currently pending? Answer for the past seven years.* *select oneYesNoAre you now, or have you ever been debarred or excluded from federal procurement programs by any federal agency or the General Services Administration, or any other government payment program? *select oneYesNoI therefore swear or affirm under penalty of perjury that I have registered with the Selective Service System, or I am exempted from such registration because of one of the following provisions of the Military Selective Service Act or Act 228 of the Arkansas General Assembly *select oneI have registeredI am femaleI am a current member of the armed forces on active dutyI am under 18 years of ageI am 26 years of age or overI am an exempted resident alienOtherIn order to comply with requirements set forth by the Equal Employment Opportunity Commission (EEOC), the following applicant data must be collected: age, gender, race, and veteran status. That said, completion of this form is optional and your application will not be affected if you decline to participate. This information will be maintained by Ozark IC for reporting purposes only, and it will not be divulged to persons who participate in the interview and selection process.select oneFemaleMaleOtherPrefer not to sayPlease indicate if you are Hispanic or Latino.select oneYesNoPlease select the ethnicity (or ethnicities) which most accurately describe(s) how you identify yourself.American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteCheck all that apply.Why are you being asked to complete this form? We are a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows and are hereafter referred to all together as “protected veterans”: A Disabled Veteran is one of the following: 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 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. 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. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with VEVRAA as amended. We are an equal opportunity employer. We do not discriminate in hiring or employment against any individual on the basis of race, color, gender, national origin, ancestry, religion, physical or mental disability, age, veteran status, sexual orientation, gender identity, marital status, pregnancy, citizenship, or any other factor protected by anti-discrimination laws.select oneI identify as one or more of the classifications of protected veterans listed aboveI identify as a veteran, just not a protected veteranI am not a veteranI do not wish to self identifyVoluntary Self-Identification of disability Form CC-305 OMB Control Number 1250-0005 Expires 04/30/2026NameEmployee ID: (if applicable)Date:Why are you being asked to complete this form? We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years. Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if you have a disability? A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to: • Alcohol or other substance use disorder (not currently using drugs illegally) • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS • Blind or low vision • Cancer (past or present) • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or serious difficulty hearing • Diabetes • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders • Epilepsy or other seizure disorder • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome • Intellectual or developmental disability • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD • Missing limbs or partially missing limbs • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS) • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities • Partial or complete paralysis (any cause) • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema • Short stature (dwarfism) • Traumatic brain injuryYes, I have a disability, or have had one in the pastNo, I do not have a disability and have not had one in the pastI do not want to answerPlease check one of the boxes below: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.Submit ApplicationPlease do not fill in this field.
