District 6 HRDC300 1st Ave. North, Suite 203Lewistown, MT 59457406-535-7488AFFIRMATIVE ACTIONVOLUNTARY INFORMATIONCompletion of information below is voluntary.We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, military/veteran status, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing the information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.Please be advised that this survey is not part of your official application for employment. The information will be used and kept confidential in accordance with applicable laws and regulations.Position(s) applied for:Date:Referral Source:Walk-inEmployeePrivate Employment AgencyRelativeGovernment Employment AgencySchoolAdvertisement - SourceOtherName of person who referred you (if applicable)APPLICANT INFORMATIONNameTelephone #LastFirstMiddleAddressStreetCity State Zip CodeMaleFemaleEEO SELF IDENTIFICATIONPlease check the box (only one) that best applies to you:Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin; regardless of race.White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific IslandsAsian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the races above, excluding Hispanic or Latino.This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified special disabled veterans, veterans of the Vietnam era, recently separated veterans, and other protected veterans. If you are a veteran of the Vietnam era, recently separated veteran, or other protected veteran, we would like to include you under our affirmative action program. If you would like to be included under the affirmative action program, please tell us. Submission of this information is voluntary and refusal to provide will not subject you to an adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that: (i) supervisors and managers may be informed regarding restrictions on work or duties of special disabled veterans, and regarding necessary accommodations; (ii) 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 (iii) government officials engaged in enforcing laws administered by OFCCP, or enforcing the Americans with Disabilities Act, may be informed.VETERAN STATUS INFORMATIONPlease check all the boxes that apply to you:I am a veteran of the Vietnam era. A person who: (a) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred in: (i) the Republic of Vietnam between February 28, 1961 and May 7, 1975 or (ii) betweenAugust 5, 1964 and May 7, 1975, in all other cases; OR (b) was discharged or released from active duty for a service-connected disability if any part of such active duty wasperformed during the times and places specified under (a).I am a recently separated veteran. Any veteran during the one-year period beginning on the date of such veteran’s discharge or release from active duty.I am an other protected veteran. A person who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized, under laws administered by the Department of Defense.I would like to be included under the company’s affirmative action program (if applicable) pertaining to veterans of the era, recently separated veterans, and other protected veterans. (Note that you may make this request at this time and/or any time in the future.None of the above apply to me.SPECIAL DISABLED VETERANS (APPLICANT: Only Complete this section if the Company has checked the “Yes” below)EMPLOYER: Please indicate whether you are inviting applicants to participate in your company’s affirmative action program benefiting special disabled veterans.Yes. The Company invites its applicants to provide information (on a voluntary basis) regarding their status as a “special disabled veteran” for inclusion in the company’s affirmative action program.Check this box ONLY if the company is actually undertaking affirmative action for special disabled veterans as the application state (pre-offer) or is otherwise authorized to collect this data to comply with federal, state, or local affirmative action obligations pertaining to special disabled veterans. Otherwise, it is advisable to wait until a conditional offer of employment has been extended before inquiring about disability status.APPLICANT:If the company has checked “Yes” to the question above, you are invited to provide additional information regarding your status as a “special disabled veteran.” This information will assist us in placing you in an appropriate position and in making accommodations for you disability. The law defines a “special disabled veteran” as: A veteran 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 Department of Veteran Affairs for a disability rated at 30 percent or more, or related at 10 or 20 percent in the case of a veteran who has been determined by the Department of Veteran Affairs to have a serious employment handicap, orA person who was discharged or released from active duty because of a service-connected disability.If you are a special disabled veteran, please indicate whether you would like to be included under the company’s affirmative action program for special disabled veterans. You may elect to be included at this time or any time in the future.Yes. I would like to be included under the company’s affirmative action program for special disabled veterans. (If a job offer is extended, you may be asked to providemore information to assist with placement and accommodation issues.)No. At this time, I would not like to be included in the company’s affirmative action program for special disabled veterans.If you are a special disabled veteran, it would assist us if you tell us about any special methods, skills, and procedures, which qualify you for positions that you might not otherwise be able to do because of your disability so that you will be considered for any positions of that kind.Applicant’s Signature: ________________________________________________________________________________________________________HiredYesNo Position hired forFrom the EEO job classifications listed below, which one best describes the position filled (or applied for, if applicant rejected)?Executive/Senior Level Officials and ManagersTechniciansCraft WorkersLaborers and HelpersFirst/Mid-Level Officials and ManagersOperativesSales WorkersService WorkersAdministrative Support WorkersProfessionalsNotes:Completed by:Date:FOR ADMINISTRATIVE USE ONLYTo be filed separately from employment application.