Form 138 - Employment Application (Page 2 of 4) in pdf

VOLUNTARY SELF‐IDENTIFICATION

The information requested below is used by Alice Manufacturing Company, Inc. only to maintain records required of

employers doing business with the federal government. YOU DO NOT HAVE TO ANSWER THESE QUESTIONS TO BE

CONSIDERED FOR EMPLOYMENT WITH ALICE MANUFACTURING COMPANY, INC. If you do choose to answer these

questions, any information supplied by you on this voluntary self‐identification form will not affect your employment

opportunities with Alice Manufacturing Company, Inc., which is an equal employment opportunity/affirmative action

employer.

Name:

Date of Application:

Job Applied For:

Referral Source:

Race/Ethnicity:

 Hispanic or Latino

 Native Hawaiian or Other Pacific Islander (Not Hispanic

or Latino)

 American Indian or Alaska Native (Not Hispanic or

 White or Caucasian (Not Hispanic or Latino)

Latino)

 Asian (Not Hispanic or Latino)

 Two or More Races (Not Hispanic or Latino)

 Black or African‐American (Not Hispanic or Latino)

 I do not wish to disclose this information

 Male

 Female

 I do not wish to disclose this information

Gender:

Self‐ID for Veterans

 If you never served in the military, check here and go to next page

This employer is 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:

 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.

Protected veterans may have additional rights under the Uniformed Services Employment and Reemployment Rights Act (USERRA). 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.

 I AM A PROTECTED VETERAN

 I AM ANOTHER TYPE OF VETERAN NOT LISTED ABOVE

 I AM NOT A PROTECTED VETERAN

 I AM A RECENTLY SEPARATED VETERAN AND

 I DO NOT WISH TO DISCLOSE THIS INFORMATION

MY DISCHARGE/RELEASE DATE IS:

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.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on

the work or duties of 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 the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may

be informed.

Form #138 (revised 2/29/2016)

2 of 4

Form 138 - Employment Application Page 2

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