Invitation To Self-Identify Form - For Veterans printable pdf download

INVITATION TO SELF-IDENTIFY – FOR VETERANS

NAME: __________________________________________________________

DATE: ________________________________________

(PLEASE PRINT)

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 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.

I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE

I AM NOT A PROTECTED VETERAN

As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the

number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected

veterans listed above, please indicate by checking the appropriate box below.

I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

DISABLED VETERAN

RECENTLY SEPARATED VETERAN

ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN

ARMED FORCES SERVICE MEDAL VETERAN

__________

I am a protected veteran, but I choose not to self-identify the classifications to which I belong.

I am NOT a protected veteran.

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the

essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily

performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for

your disability.

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 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 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.

Our Company is committed to equal employment opportunity. We will not discriminate or retaliate against employees or applicants for employment on

any legally-recognized basis including, but not limited to age, race, color, religion, sex, gender, pregnancy, national origin, ancestry, disability, armed

services veteran status (including any protected and/or disabled veteran status), genetic characteristic, whistleblower status, marital status, or any other

characteristic or classification protected by applicable federal, state, or local law.

Obtained from ECFR Website -- e-CFR Data is current as of February 2, 2015 (Title 41, Subtitle B, Chapter 60, Part 60-300, Subpart E – Sample Self-Identification Form

Invitation To Self-Identify Form - For Veterans

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