Truck Driver Application (complete for Driver Positions Only) "*" indicates required fields Step 1 of 9 11% THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT but merely is intended to evaluate suitability for employment. Should you need assistance with this application, please contact Lori Hall at (270) 362-8661. It is the policy of the Company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, marital status, national origin, citizenship, disability, veteran status, and any other legally protected status under state and federal law. We encourage women and minority to apply. It is also the policy of the Company to have the option of conducting preemployment screening before a job offer is made. If a job offer is made, employment may be contingent upon a successful completion of a medical examination, which may include providing body substance samples.Date* Month Day Year Name* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long?* Email* PhoneCell PhoneDate of Birth* Month Day Year List your addresses of residency for the past 3 yearsPrevious Address #1 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long? Previous Address #2 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long? Previous Address #3 Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Long? Do you have legal right to work in the United States?* Yes No Have you worked for this company before?* Yes No If yes, when? Reason for Leaving? Are you currently employed?* Yes No Who referred you?* Rate of pay expected* EMPLOYMENT RECORD DOT requires that all applicants wishing to drive a commercial motor vehicle must provide the following information on all previous employers during the proceeding 3 years. You must give the same information for whom you have driven a commercial motor vehicle for an additional 7 years. You are required to list the complete address: Street number and name, city state and zip code. Any gaps in employment and/or unemployment must be explained.Current or Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Second Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Third Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Fourth Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Fifth Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Sixth Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Seventh Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason Eighth Last Employer:Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From Month Day Year To Month Day Year Reason for leaving Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode, subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for time between jobs (month/year) and reason EXPERIENCE & QUALIFICATIONSLicense List all Driver's license(s) held within the last 3 years.License Type #1 State Expiration Date Month Day Year Number License Type #2 State Expiration Date Month Day Year Number If you have CDL, list CDL endorsements: Has your license(s) ever been denied renewal, revoked or suspended? If yes, please explain Yes No License Type #1 Action Taken Date Month Day Year Reason License Type #2 Action Taken Date Month Day Year Reason License Type #3 Action Taken Date Month Day Year Reason Experience Indicate number of years' experience and types of vehicle (trucks, tractors, semi-trailers, buses etc.) If no driving experience within last 3 years - check hereYears Type of Vehicle Years Type of Vehicle Years Type of Vehicle Accidents Please indicate all accidents (company and personal) during the past 3 years If no accidents within the last 3 years - check hereDate of Accident #1 Month Day Year Nature of Accident (head-on, Rear-end, Sideswipe, etc.) Injury/Fatalities Hazardous Materials Spill Yes No Date of Accident #2 Month Day Year Nature of Accident (head-on, Rear-end, Sideswipe, etc.) Injury/Fatalities Hazardous Materials Spill Yes No Date of Accident #3 Month Day Year Nature of Accident (head-on, Rear-end, Sideswipe, etc.) Injury/Fatalities Hazardous Materials Spill Yes No Violations List all moving violations (company and personal) during the last 3 years (other than parking) If no traffic convictions and/or forfeitures in the last 3 years - check hereDate of Violation #1 Month Day Year Offense Location Fine/Determination Date of Violation #2 Month Day Year Offense Location Fine/Determination Date of Violation #3 Month Day Year Offense Location Fine/Determination Training Please indicate driver safety training programs completedDate of Training #1 Month Day Year Location Course Type / Conducted By Date of Training #2 Month Day Year Location Course Type / Conducted By Awards Please indicate all safe driving awards you've receivedDate of Award #1 Month Day Year Location Type of Award Organization Date of Award #2 Month Day Year Location Type of Award Organization TO BE READ & BE SIGNED BY APPLICANT This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (General, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand that I am required to abide by all rules and regulations of Jim Smith Contracting Co., LLC.Consent I agree to the privacy policy.Today's Date* Month Day Year Applicant's Signature* Release of Information Consent Form* I consent to the Release of Information below:CONFIDENTIAL I certify and declare under penalty of perjury under relevant state and federal law that the information contained in my employment application and this form is complete, true and accurate. I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of employment. In consideration of Jim Smith Contracting review of my application for employment, I hereby voluntarily consent to and authorize Jim Smith Contracting or Kelmar Safety Inc (authorized agent), to obtain consumer reports for employment purposes. This may include but not limited to Employment Verifications, Motor Vehicle Reports, References and Criminal reports. This release specifically covers verifying your Education-High Schools, GED, Colleges, Degrees or Technical Schools. I authorize all persons and organizations that may have information relevant to this research to disclose such information to Jim Smith Contracting or Kelmar Safety Inc (authorized agent). I hereby release Jim Smith Contracting and Kelmar Safety Inc (authorized agent), and all persons and organizations providing information from all claims and liabilities of any nature in connection with this research. Purposes of investigation as required by Section 391.23 and Part 382 and part 40 of the Federal Motor Carrier Safety Regulations also apply. I hereby give specific permission to past employers to release drug and alcohol test results or SAP information. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original. I understand that I have specific prescribed rights as a consumer under the Federal Fair Credit Reporting Act ('FCRA'), and may have additional rights under relevant state law. I hereby certify that I have been presented with a summary of my rights as a consumer under the Fair Credit Reporting Act.Full Name* Date* Month Day Year Signature*Date of Birth* Month Day Year Drivers License #* State* I understand the information I am providing about date of birth will not be used to determine eligibility for employment, but will be used solely for the purpose of obtaining background check information only and this consent is given for one time only. Any subsequent checks will require new consent. Have you ever been convicted of any crime?* If yes, please provide Year of conviction, County, Parrish, State and Type of Conviction: THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERSIMPORTANT DISCLOSUREPlease Check the Box to Consent Below* In connection with your application for employment with Jim Smith Contracting Co., LLC, Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization. AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Jim Smith Contracting Co.,LLC ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear 2 on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.Signature*Date* Month Day Year Name* NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language. Voluntary Self-Identification of “Protected” Veteran StatusWhy Are You Being Asked to Complete This 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). VEVRAA requires Government contractors to take affirmative action to employ and advance in employment protected veterans. To help us measure the effectiveness of our outreach and recruitment efforts of veterans, we are asking you to tell us if you are a veteran covered by VEVRAA. Completing this form is completely voluntary, but we hope you fill it out. Any answer you give will be kept private and will not be used against you in any way. 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. How Do You Know if You Are a Veteran Protected by VEVRAA? Contrary to the name, VEVRAA does not just cover Vietnam Era veterans. It covers several categories of veterans from World War II, the Korean conflict, the Vietnam era, and the Persian Gulf War which is defined as occurring from August 2, 1990 to the present. If you believe you belong to any of the categories of protected veterans please indicate by checking the appropriate box below. The categories are defined on the next page and explained further in an “Am I a Protected Veteran?” infographic provided by OFCCP. What Categories of Veterans Are “Protected” by VEVRAA? “Protected” veterans include the following categories: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and These categories are defined below. 1. 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. 2. 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. 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. Please choose from one of the options below:* I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM NOT A PROTECTED VETERAN I DO NOT WISH TO ANSWER Name* First Last Date* MM slash DD slash YYYY EEO-1 Voluntary Self Identification Form The Equal Employment Opportunity Commission (EEOC) requires all private employers with 100 or more employees as well as federal contractors and first-tier subcontractors with 50 or more employees AND contracts of at least $50,000 complete an EEO-1 report each year. Covered employers must invite employees to self-identify gender and race for this report. Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. Please return completed forms to the HR department. If you choose not to self-identify your race/ethnicity at this time, the federal government requires Jim Smith Contracting to determine this information by visual survey and/or other available information. Name* First Last Date* MM slash DD slash YYYY Gender*GenderMaleFemaleRace / Ethnicity*Race / EthnicityHispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa.Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.Third ChoiceNative Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.I do not wish to disclose. Voluntary Self-Identification of Disability Why are you being asked to complete this form? We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. How do you know if you 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: • Autism • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Blind or low vision • Cancer • Cardiovascular or heart disease • Celiac disease • Cerebral palsy • Deaf or hard of hearing • Depression or anxiety • Diabetes • Epilepsy • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Intellectual disability • Missing limbs or partially missing limbs • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression Yes, I Have A Disability, Or Have A History/Record Of Having A Disability* Yes, I Have A Disability, Or Have A History/Record Of Having A Disability No, I Don’t Have A Disability, Or A History/Record Of Having A Disability I Don’t Wish To Answer CAPTCHAAnti-Spam Question: How many units are in a dozen? 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