Federal laws and regulations require us to report on our workforce by race, gender, and veteran status and to offer the opportunity for self-identification as to disabilities. Please assist us by completing this form. YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION. Data which you provide shall be kept strictly confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work and duties of disabled individuals and/or disabled veterans; (ii) first aid and safety personnel may be informed, to the extent appropriate, if the condition might require emergency treatment; and (iii) governmental officials reviewing the Company's compliance status shall be informed.
* Categories consistent with 41 C.F.R. 60-300 & Form VETS-100A
If you need a definition of these terms, please see below.
SELF - IDENTIFICATION FORM DEFINITIONS
1. The term "Disabled Veteran" means -
A. a veteran 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; or
B. a person who was discharged or released from active duty because of a service-connected disability.
2. The term "Recently Separated Veteran" applies to any veteran during the three-year period beginning on the date of discharge or release from active duty.
3. An "individual with a disability" means any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities; (ii) has a record of such impairment; or (iii) is regarded as having such impairment.
Are there any other experiences, skills, or qualifications which you feel are relevant to this job that have not already been mentioned?
I hereby certify that the answers given by me to all the questions contained on this application form are true and correct. If employed by Caremed, Inc. I will comply with all rules, regulations, policies and procedures of the company. I authorize my former employers to give any information they have regarding me, whether or not it is on their records. I authorize Caremed, Inc. to run a background check. I hereby release them and Caremed, Inc. from all liability for any damage whatsoever for issuing same. If upon investigation, anything in this application is found to be untrue, I understand I will be subject to dismissal, and/or prosecution to the fullest extent
of the law.