General Information

Education

Military Service

References

List two personal references who are not relatives or former supervisors.

Employment History

List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to the job you are applying for are listed here, or in the summary following this section.

Equal Employment Opportunity:  While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no effect on your application for employment.

Application Self-Identification Form

Providing this information is strictly voluntary on your part, and is not required to complete your Application for Employment. Nor, will providing the information or not providing the information affect the outcome of your application.

Federal government regulations require Southern Earth Sciences, Inc. to maintain records of job applicants by gender and race. Additionally, we collect this information to ensure that we are monitoring our own success in encouraging diverse applicants.

Please assist us by providing the requested information. Providing this information is strictly voluntary on your part, and is not required to complete your Application for Employment.

Pre-Offer Protected Veteran Self-Identification Form

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:

1. “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.

2. “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.

3. 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.

4. 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.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.ⁱ  To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability.  Completing this form is voluntary, but we hope that you will choose to fill it out.  If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way.  Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years.  You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

ⁱ Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.