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General Information:

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Race / Ethnicity:

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American Indian or Alaskan Native
    A person having origins in any of the original peoples of North and South America (including Central America), and who maintains cultural identification through community recognition or tribal affiliation.
Asian
    A person having origins in any of the original peoples of the Far East, Southeat Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, kprea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American
    A person having origins in any of the black racial groups of Africa.
Hispanic / Latino
    A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
Native Hawaiian or Other Pacific Islander
    A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White
    A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Two or More Races
    A person who identifies with more than one of the above six races.
Declined to Self Identify



Gender:

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Male   Female   Decline to Self Identify  



Veterans Code:


Disabled Veteran - means (1) a veteran of the US Military, ground, naval or air service who is entitled to compensation (or who but for the receipt of the military retired pay would be entitled to compensation) under laws administered by the Secretary of Veteran’s Affairs or (2) a person who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veterans' – means a 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.

Active duty wartime or campaign badge Veterans' – 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.

Armed forces service medal Veterans' – 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.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

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.

Veterans Self Identification:

Please check all that apply.

I am Not a protected Veteran.
I identify as one or more of the classifications of Protected Veteran listed above.



Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 1 of 2

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. To help us measure how well we are doing, 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)
  • Yes, I have a disability (or previously had a disability)
    No, I do not have a disability
    I don't wish to answer

    Check this box to Agree and sign the CC-305 Form
    Form CC-305
    OMB Control Number 1250-0005
    Expires 1/31/2017
    Page 2 of 2
    Reasonable Accomodation 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 0MB control number This survey should take about 5 minutes to complete.




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    Equal Opportunity Employer

    Rossi Contractors, Inc. is an equal opportunity employer.