Affirmative Action And Voluntary Self-Identification Of Disability Form For Applicants printable pdf download

AFFIRMATIVE ACTION AND VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

FORM FOR APPLICANTS

NAME________________________________________________________________

Please Print

Date _____________

Position_______________________________________

Molin Concrete Products Company is subject to Federal and State governmental

recordkeeping and reporting requirements. The following information is necessary to

comply with Federal Executive Order 11246, Section 503 of the Rehabilitation Act of

1973, as amended, and Minnesota nondiscrimination guidelines+. Your response is

voluntary; you will not be treated adversely if you refuse to complete this form. This

information is maintained separately from any application or employment information.

When it is used for reporting it will not identify any specific individual.

Check appropriate information below

□Male

□Female

Gender

Race/Ethnicity

□ Hispanic or Latino

□ White

□ Black/African American

□ Asian

□ Native Hawaiian or Other Pacific Islander

□ American Indian or Alaska Native □ Two or more Races

To help measure how well we are doing reaching out to hire and provided equal

opportunity to qualified people with disabilities 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

you will choose to answer. 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.

You are considered to have a disability if you have a physical or mental impairment or a

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:

*Blindness

*Autism

*Bipolar Disorder

*Post-Traumatic Stress Disorder (PTSD)

*Deafness

*Cerebral Palsy *Major Depression

*Obsessive Compulsive Disorder

*Cancer

*HIV/AIDS

*Multiple Sclerosis

*Impairments requiring wheelchair use

*Diabetes

*Schizophrenia *Missing limbs or

*Intellectual disability (previously called

*Epilepsy

*Muscular

partially missing

mental retardation)

Dystrophy

limbs

Please check the appropriate box: ⃞Yes, I have a disability (or previously had a

disability) ⃞No, I do not have a disability ⃞I do not wish to answer

Are you a Veteran? ⃞Yes

⃞No

⃞Yes

Vietnam Era

Disabled Veteran ⃞Yes

⃞No

How did you learn about this position?_____________________________________

+ For more information about this form or the equal employment obligations of Federal contractors, visit the

US Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) @

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Affirmative Action And Voluntary Self-Identification Of Disability Form For Applicants

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