[Note: This form can be used to collect veteran status, gender and race/ethnicity on one form, which would apply to both the VEVRAA and Executive Order 11246, which requires affirmative action for women and minorities.
Federal contractors under VEVRAA should ask the applicant if he or she is a protected veteran, but wait until after a job offer has been accepted to ask the individual to specify which veteran category or categories apply to him or her.]
[Company Name] is an equal opportunity employer. As required by law, we must record certain information to be made a part of our affirmative action program.
Applicants for employment are invited to participate in the affirmative action program by reporting their status as a protected veteran or other minority. In extending this invitation, we advise you that: (a) workers (applicants) are under no obligation to respond but may do so in the future if they choose; (b) responses will remain confidential within the human resource department; and (c) responses will be used only for the necessary information to include in our affirmative action program. We are a company that values diversity. We actively encourage women, minorities, veterans and disabled employees to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Name: Position Applied for:
Gender
Race or Ethnicity (select one)
Veteran Status**
Date Completed:
How did you hear of our opening?
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*EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES
Hispanic 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.
Native Hawaiian or Other 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.
American Indian 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 maintain tribal affiliation or community attachment.
Two or more races (not Hispanic or Latino) - All persons who identify with more than one of the above races.
**PROTECTED VETERAN DEFINITION
Protected veteran means a veteran who may be classified as an active duty wartime or campaign badge veteran, disabled veteran, Armed Forces service medal veteran or recently separated veteran.
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.
Armed Forces service medal veteran means any 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 (61 FR 1209, 3 CFR, 1996 Comp., p. 159).
Disabled veteran means (1) 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 (2) a person who was discharged or released from active duty because of a service-connected disability.
Recently separated veteran means a 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.