Employment Form

From: Name of Applicant: Position applying for: Dear Prospective Employee, We are subject to section 503 and 504 of the Rehabilitation Act of 1973 and section 402 of the Vietnam Era Veterans Re-adjustment Assistance Act of 1974, which requires government contractors to take affirmative action to employ and advance in employment qualified disabled veterans, veterans of the Vietnam era, and handicapped individuals. If you meet the above description, we would like to include you under the affirmative action program. Also if you are a disabled veteran or handicapped, it would assist us if you would tell is about 1 Any special methods skills or procedures which quality you for the positions that you might not otherwise be able to do because of your disability so that you will be considered for any position of that kind The accommodations that we could make that would enable you to perform the job properly and safely including reasonable changes in the physical layout of the job alterations of certain duties relating to the job or other accommodations 2 This information is voluntary and will be kept confidential Refusal to provide this information will not subject you to any adverse treatment. Your voluntary cooperation is greatly appreciated. Did you serve on active duty for more than 180 days, any part occurring between 8/5/64 and 5/7/75? Yes where you discharged or released from the above active duty because of a service related disability? Are you entitled to disability compensation by the Veterans Administration for 30% or more rated disability? No No No Yes Yes Are you entitle to disability compensation by the Veteran Administration for a 10% or 20% rated disability and have been determined under Section 1506 of Title 38, U.S.C to have a serious employment handicap? Yes DO you have a physical or mental impairment which limits one or more of your major life activities? If yes, please explain: No Yes Are there any special methods, skills or procedures which qualify you for the position that you might not otherwise be able to do because of your disability, so that you will be considered for any position of that kind? please list the methods and/or skills: No Yes No Are there any reasonable accommodations we could make which would enable you to perform the job? Please list the accommodations Yes No <INVITET.FT2> American LegalNet, Inc. www.FormsWorkFlow.com 2001 © American LegalNet, Inc.