Fillable Employment Application Form (Classified Staff) (Page 4 of 4) in pdf

ALL INFORMATION BELOW IS OPTIONAL AND CONFIDENTIAL

This page is used by the Human Resources Office only and is not seen by the hiring department.

Position information

Veteran status information

This employer is a government contractor subject to the

____________________________________________________

Vietnam Era Veterans’ Readjustment Assistance Act of

Job title

1974, as amended by the Jobs for Veterans Act of 2002,

____________________________________________________

38 U.S.C. 4212 (VEVRAA), which requires government

Department/office

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

Recruitment number

veterans; and (4) Armed Forces service medal veterans.

These classifications are defined as follows:

Western Oregon University is committed to an affirmative action

program that promotes the effective recruitment of women, members

• A disabled veteran is one of the following:

of racial/ethnic groups, individuals with disabilities, veterans, LGBTQ+

o A veteran of the U.S. military, ground, naval, or air

and community members, and others who demonstrate the ability to

service who is entitled to compensation (or who but

hlep us achieve our vision of a diverse and inclusive community. The

for the receipt of military retired pay would be entitled

information in this document will be kept confidential and used to

to compensation) under laws administered by the

fulfill reporting requirements. Completion of this form is voluntary; a

Secretary of Veterans Affairs; or

decision not to disclose this information will not result in any adverse

treatment of your employment application.

o A person who was discharged or released from active

duty because of a service-connected disability.

• A recently separated veteran means any veteran during

Demographic information

the three-year period beginning on the date of such

veteran’s discharge or release from active duty in the

In what city and state do you live?

U.S. military, ground, naval, or air service.

City: _____________________________________ State: _________

• An active duty wartime or campaign badge veteran

means a veteran who served on active duty in the U.S.

If in Oregon, what county: __________________________________

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

Affirmative Action information

the Department of Defense.

Gender (check one): q Male q Female q Trans or

• An Armed Forces service medal veteran means a

gender non-conforming

veteran who, while serving on active duty in the U.S.

Please indicate your ethnic identity by answering the

military, ground, naval, or air service, participated

following question:

in a United States military operations for which an

Are you Hispanic or Latino? q Yes q No

Armed Forces service medal was awarded pursuant to

Executive Order 12985.

Race (choose one or more):

q Asian or Pacific Islander: All persons having origins in

Please check one of the boxes below (Please provide a

any of the peoples of the Far East, Southern Asia, the

copy of your DD-14 to prove eligibility):

Indian subcontinent, or the Pacific Islands. For example,

this area includes, China, India, Japan, Korea, the

q I identify as one or more of the classifications of

Philippine Islands, and Samoa.

protected veteran listed above.

q Black (Not of Hispanic origin): All persons having origins

q I am not a protected veteran.

in any of the Black racial groups of Africa.

q Hispanic: All persons of Mexican, Puerto Rican, Cuban,

Central or South American or other Spanish culture or

Advertising information

origin, regardless of race.

q Native American or Alaskan Native: All persons having

Where did you first learn about this position?

origins in any of the original peoples of North America,

q Printed advertisement q Webpage

q Other

and who maintain cultural identification through tribal

affiliation or community recognition.

Please specify: ___________________________________

q White (Not of Hispanic origin): All persons having origins

in any of the original peoples of Europe, North Africa,

___________________________________

or the Middle East.

Employment Application Form (Classified Staff) Page 4

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