Self-Identification For Veteran Status Form

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Self-identification for Veteran Status (pre-offer)
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 the following
categories of veterans:
Disabled veteran:
- 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.
Recently separated veteran: 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.
Active duty wartime or campaign badge veteran: 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 veteran: a veteran who, while serving on active duty in the U.S. military,
ground, naval, or air service, participated in a U.S. military operation for which an Armed Forces service
medal was awarded pursuant to Executive Order 12985.
Please print your name below and indicate whether you belong to any of the above-mentioned categories of
protected veterans.
Note: 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. Refusal to provide it does not subject you to any adverse treatment. The information provided
will be kept confidential and used only in ways that are consistent with the Vietnam Era Veterans' Readjustment
Assistance Act of 1974, as amended.
Name:
Date:
I identify as one or more of the classifications of protected veteran listed above (there is no need to identify
the specific category at this time).
I am not a protected veteran.
I choose not to provide any information regarding my veteran status (you may choose to provide this
information at any time in the future).
About our affirmative action plan
The company's affirmative action plan asserts and outlines our commitment to ensuring that our policy of
nondiscrimination and affirmative action is accomplished. Specifically, the company does not discriminate on the
basis of veteran status and works to employ and advance in employment qualified protected veterans.
The company's affirmative action efforts include a regular review of personnel processes and the physical and
mental job qualification standards for individual positions. They also include employee training, efforts to prevent
harassment, and data collection and reporting systems to ensure nondiscrimination.

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