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PRE-EMPLOYMENT VOLUNTARY QUESTIONNAIRE

 

As an equal opportunity employer, we are obligated by Federal and State regulations to monitor our employment practices. To ensure the accuracy of this information, your assistance in this questionnaire will be greatly appreciated. Information concerning race, sex, veteran's status or disability will not be used to discriminate against or give preference to any individual. This data will be kept separate from the personnel file and is used for statistical purposes only. Response is voluntary and answers will remain confidential.

RACE OR ETHNIC GROUP
White/Caucasuan  Black  Asian/Pacific Islander  Hispanic or Spanish Surname  American Indian or Alaskan Native 

SEX
 Male   Female

INDIVIDUALS WITH DISABILITIES
A disabled individual is anyone who has a physical impairment which substantially limits one or more of such person's major life activities; or has a record of such impairment; or is regarded as having such an impairment. For purposes of this Questionnaire, a disabled individual is "substantially limited" if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of a disability.
Do you have a disability?   Yes   No

DISABLED VETERANS
A disabled veteran is a person who: is entitled to disability compensations under laws administered by the Veterans Administration for disability rated 30 percent or more; or was discharged or released from active duty due to a disability incurred or aggravated in the line of duty.
Are you a disabled veteran?   Yes   No

VETERANS OF THE VIETNAM ERA
A veteran of the Vietnam Era is a person who: served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged other than dishonorable; or was discharged or released from active duty for a service-connected disability if any part of such duty was performed between August 5, 1964 and May 7, 1974.
Are you a veteran of the Vietnam Era?   Yes   No

OTHER ELIGIBLE VETERANS
An Other Eligible Veteran is defined as a veteran who served in a "war". This group also includes those veterans who served in a campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary medal has been awarded, which includes a number of military engagements.
Are you an Other Eligible Veteran?   Yes   No

Applicant's Name: 
Date: 



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