INVITATION TO VETERANS AND/OR HANDICAPPED
From _________________________ ______________________________ Name of Applicant ______________________
Position applying for _____________________
As a government contractor, we are subject to sections 503 and 504 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Veterans Re-adjustment Assistance Act of 1974. These Acts require 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 one or more of the above descriptions, we would like to include you under the affirmative action program.
This information is completely voluntary and will be kept confidential. Refusal to provide this information will not subject you to any adverse treatment. However, your cooperation in this matter would be greatly appreciated.
If you are a disabled veteran or handicapped individual, it would assist us if you tell us about:
1) Any special methods, skills or procedures which qualify you for positions that you might not otherwise be able to competently perform because of your disability. By listing these special methods, skills, or procedures, you may be considered for a broader range of positions.
2) Accommodations we could make that would enable you to perform the job properly and safely. These accommodations may include instituting reasonable changes in the physical layout of the job, alterations of certain duties relating to the job, or other accommodations.
Did you serve on active duty for more than 180 days, any part occurring between 8/5/64 and 5/7/75? [ ] Yes [ ] No
Were you discharged or released from the above active duty because of a service-connected disability? [ ] Yes [ ] No
Are you entitled to disability compensation by the Veterans Admin. for a 30% or more rated disability? [ ] Yes [ ] No
Are you entitled to disability compensation by the Veterans 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 [ ] No
Do you have a physical or mental impairment which limits one or more of your major life activities? [ ] Yes [ ] No
If yes, please explain __________________________________________________ __________________________________________________________________ __________________________________________________________________
Are there any special methods, skills or procedures which qualify you for positions that you might not otherwise be able to function in because of your disability? If so, you will be considered for any positions of that kind. [ ] Yes [ ] No
Please list these methods and or skills ______________________________________ ___________________________________________________________________ ___________________________________________________________________
Are there any reasonable accommodations we could make which would enable you to perform the job? [ ] Yes [ ] No
Please list the accommodations _____________________________________________ _____________________________________________________________________ _____________________________________________________________________