Affirmative Action Form Affirmative Action Employee Self-identification Information Affirmative Action Employee Self-identification InformationVetPride Services, Inc. actively works to recruit, employ and advance employment opportunities for minorities, women, disabled veterans and protected veterans. Our ongoing effort ensures that we maintain a diverse and well-qualified workforce, and comply fully with the Governments affirmative action requirements. As part of our program, and to help us monitor our success, we ask that every employee consider providing us necessary information by completing the questionnaire below. The information will be exclusively used to assist in completing federally mandated reports related to race, gender, disability, and veteran status of applicants for any given position. This information is not mandatory. Your participation is voluntary, and should you decide to not to provide the requested information, it will not be detrimental to any future employment decisions related to you. This information will be kept completely separate from your personnel file, and will not be accessible to persons involved in the hiring process. Name First Last Requested Job Position: Gender: Male Female I prefer not to participate Race or Ethnicity: American Indian/Alaskan Native (not Hispanic or Latino): A person in this group has origins in any of the original peoples of North America and maintain a cultural affiliation through affiliation with a tribe or community. Asian: A person in this group has origins in any of the peoples of the Far East, Southeast Asia or India. It includes people from Pakistan, Cambodia, Thailand, Vietnam, China, Japan, Korea, or Malaysia. Black or African American (not Hispanic or Latino): A person in this group traces his or her origins to any of the Black racial groups of Africa. Hispanic or Latino: A person in this group is of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. White (not Hispanic or Latino): A person in this group has origins in any people originally from Europe, North Africa or the Middle East. Two or more Races (not Hispanic or Latino): A person in this group identifies with two or more races, but is not of Hispanic origin. I prefer not to participate Please only check one box. If you are of more than one group, please check the one with which you most closely identify yourself. Veteran Status: Special Disabled Veteran. I am 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 Department of Veterans' Affairs for a disability (A) rated at 30 percent or more, or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap or a person who was discharged or released from active duty because of a service connected disability. Vietnam Era Veteran. I am a person who served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975, in all other cases; or was discharged or released from active duty in the U.S. military, ground, naval or air service for a service connected disability if any part of such active duty was performed either in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975, in any other location. Recently Separated Veteran. I am a veteran of a branch of the United States military and was released or discharged within the last year. Other Protected Veteran. Although none of the above veteran descriptions apply to me, I am a veteran and served on active duty with a branch of the United States military during a war, campaign, or expedition for which a campaign badge was authorized, OTHER than for special disabled veterans or Vietnam veterans. I prefer not to participate Please complete only if you have served in a branch of the United States military. Please check all that apply.
