Post-Offer Voluntary Self-Identification Form (Page 2 of 2) in pdf

POST-OFFER VOLUNTARY SELF-IDENTIFICATION FORM (PAGE 2)

VIETNAM-ERA VETERAN: Are you a veteran of the Vietnam era? A veteran of the

Vietnam era means a person who: (a) served on active duty for a period of more than 180 days,

and was discharged or released with other than a dishonorable discharge, if any part of the

person’s active duty occurred: (1) in the Republic of Vietnam between February 28, 1961, and

may 7, 1975; or (2) between august 5, 1964, and May 7, 1975, in all other cases; or (b) was

discharged or released from active duty for a service-connected disability of any part of the

person’s active duty was performed: (1) in the republic of Vietnam between February 28, 1961,

and may 7, 1975; or (2) between august 5, 1964, and May 7, 1975, in all other cases.

Yes

SPECIAL DISABLED VETERAN: Are you a special disabled veteran? A special

disabled veteran means (1) a veteran who is entitled to compensation (or who but for the receipt

of military retired pay would e entitled to compensation) under laws administered by the

Veteran’s Administration for a disability (a) rated at 30 percent or more, or (b) rated at 10 or 20

percent in the case of a veteran who has been determined under Section 1506 to Title 38, U.S.C.,

to have a serious employment disability; or (2) a person who was discharged or released from

active duty because of a service-connected disability.

Yes

OTHER PROTECTED VETERANS: Are you a veteran who served on active duty

during a war or in a campaign or expedition for which a campaign badge has been authorized?

(Examples: World war II, Korea, the Persian Gulf War, Desert Storm, Bosnia, or Somalia)

Yes

DISABLED INDIVIDUAL: Are you a disabled individual? A disabled individual

means any person who (1) has a physical or mental impairment that substantially limits one or

more major life activity; (2) has a record of such an impairment; or (3) is regarded as having

such an impairment.

Yes

Do you have any limitations due to your disability that may affect your ability to

satisfactorily perform the position which for you have applied?

Yes

YES, please explain:

Are there any accommodations we could make that would enable you to perform the job

properly and safely?

Yes

YES, please explain:

Signature of Applicant

Date

Post-Offer Voluntary Self-Identification Form Page 2