Apply for General Application
Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.
If you are an applicant in need of assistance or an accommodation in the Application Process please email Applications@blakleys.com or call
317-576-8347.
2020 - Voluntary Self-Identification of Disability CC-305
Voluntary Self-Identification of Disability
Form CC-305
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OMB Control Number 1250-0005
Expires 05/31/2023
Expires 05/31/2023
Name:
Employee ID:
(if applicable)
Date:
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 peoplewith disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individualswith 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
Please check one of the boxes below:
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
I Don’t Wish To Answer
No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
I Don’t Wish To Answer
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
For Employer Use Only
Employers may modify this section of the form as needed for recordkeeping purposes.
For example:
Job Title:
Date of Hire:
VEVRAA
This employer is a government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1874, 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 below:
"Disabled veteran" is one of the following:
"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 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.
Protected veterans may have additional rights under USERAA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll free, at 1-866-4-USA-DOL.
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 Veteran’s 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.
"Disabled veteran" is one of the following:
- Veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
- Person who was discharged or released from active duty because of a service-connected disability
"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 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.
Protected veterans may have additional rights under USERAA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll free, at 1-866-4-USA-DOL.
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.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERANS LISTED ABOVE I AM NOT A PROTECTED VETERAN |
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 Veteran’s 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.
Equal Opportunity Employer Pre-Offer
It is the policy of The Blakley Corporation that there shall be no discrimination in employment ( including recruiting, hiring, promotion, compensation, and any other condition, or privilege of employment) on the basis of status as a disabled veteran, Vietnam era veteran ( as defined in 38USC Sec. 4211 41 CFR 60-250) or as a veteran who has served on active duty during a war or in an active campaign or expedition for which a campaign badge has been authorized, with regard to any position for which such individual may be qualified. This policy is intended to be in compliance with The Blakley Corporation's obligation as a federal contractor under The Vietnam Era Veteran's Readjustment Assistance Act, specifically 38 USC Sec. 4212, and it's implementing regulations, 41 CFR 60-250.
It is this Company's policy to provide equal employment opportunities to all employees in accordance with all applicable laws, directives and regulations of federal, state and local government bodies. It is out policy to recruit, hire, train and promote individuals in all employment positions without regard to race, color, religion, sex, national origin, age, veteran status or disability.
The following information is being requested so that we may comply with the law and our Equal Employment Opportunity Policy. COMPLETION OF THIS SECTION IS VOLUNTARY. No adverse treatment will result from your refusal to provide this information. This information will only be used for statistical analyses and compliance reporting. It will not be placed in your personnel file.
It is this Company's policy to provide equal employment opportunities to all employees in accordance with all applicable laws, directives and regulations of federal, state and local government bodies. It is out policy to recruit, hire, train and promote individuals in all employment positions without regard to race, color, religion, sex, national origin, age, veteran status or disability.
The following information is being requested so that we may comply with the law and our Equal Employment Opportunity Policy. COMPLETION OF THIS SECTION IS VOLUNTARY. No adverse treatment will result from your refusal to provide this information. This information will only be used for statistical analyses and compliance reporting. It will not be placed in your personnel file.
* Gender: |
Male Female I Choose Not to Respond |
* Race / Ethnicity: |
American Indian or Alaska Native (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Hispanic or Latino Asian (Not Hispanic or Latino) White (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino) I Choose Not to Respond |