Application—EVENING/WEEKEND/OVERNIGHT

APPLICANT DATA SHEET

To meet government reporting requirements, applicants are requested to answer the questions below. Please note you are not obligated to self-identify, and any information you voluntarily provide will be kept confidential in accordance with appropriate legislation. Any answers provided or refusal to self-identify will not affect any hiring decisions.

Name*

First Last

Address*

Street Address City State ZIP Code

Race/Ethnic Data

Please check one box only.

The following race/ethnic definitions are developed and provided by the Department of Labor.*

Hispanic or Latino - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin - regardless of race.
White - (not of Hispanic or Latino origin) Persons having origins in Europe, North Africa or the Middle East.
Black Or African American (not of Hispanic or Latino origin) Persons having origins in the black racial groups of Africa as well as Jamaica, Trinidad or the West Indies.
Asian - (not of Hispanic or Latino origin) 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.
American Indian or Alaskan Native - (not of Hispanic or Latino origin) A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander (not of Hispanic or Latino origin) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Two or More Races - (not of Hispanic or Latino origin) All persons who identify with more than one of the previous five races.
Do not wish to identify race.

Sex*

Male
Female

Specific Job Applied For (your 1st choice)*

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 previously had a disability)
No, I don't have a disability
I don't wish to answer

CANDIDATE VOLUNTARY SELF-IDENTIFICATION OF PROTECTED VETERAN STATUS

VOLUNTARY SELF-IDENTIFICATION - Cottonwood 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: A “disabled veteran” is one of the following: o 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 o a person who was discharged or released from active duty because of a service-connected disability. • 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. • 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. • 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. 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. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.*

I identify as one or more of the classifications of protected veterans listed above.
I am not a protected veteran.
I do not wish to identify.

Upload Additional Documents

Upload resume and/or other documents

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JOB INTEREST

AVAILABILITY

EDUCATION

WORK HISTORY - Last 3 positions

APPLICANT DATA SHEET

Race/Ethnic Data

Voluntary Self-Identification of Disability

CANDIDATE VOLUNTARY SELF-IDENTIFICATION OF PROTECTED VETERAN STATUS