Position Application Applicant Information Resume: (.doc, .docx, .pdf) First Name: Middle Name: Last Name: Address1: Address2: City: State: Zip: Phone: Email: Date Available: Desired Salary: $ Are you a citizen of the United States? Yes No Have you previously worked for Palski & Associates? Yes No Have you ever been convicted of a felony? Yes No How did you hear about this position? Are eligible and willing to acquire a security clearance? Yes No Are you willing to work onsite? Yes No References Please list three professional references Full Name: Company: Relationship: Phone: Full Name: Company: Relationship: Phone: Full Name: Company: Relationship: Phone: Affirmative Action: Applicant Invitation to Self-Identify: Veteran, Gender and Race (VEVRAA & EO 11246) Palski & Associates 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. Gender: Male Female Race or Ethnicity: Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or otherSpanish culture or origin regardless of race. White – A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American – A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander – A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian – 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 – 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 – All persons who identify with more than one of the above races. — Please select an option — Hispanic or Latino White (not Hispanic or Latino) Black or African American (not Hispanic or Latino) Native Hawaiian or Pacific Islander (not Hispanic or Latino) Asian (not Hispanic or Latino) American Indian or Alaskan Native (not Hispanic or Latino) Two or more races (not Hispanic or Latino) Veteran Status: 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 — Please selection an option — I am a protected veteran I am NOT a protected veteran I do not wish to self-identify Voluntary Self-Identifcation of Disability We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals with 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. 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 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 select an option from the menu below: — Please select an option — Yes, I have a disability, or have a history/record of having a disability No, I do not have a disability, or a history/record of having a disability I do not 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. Terms and Conditions I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Palski & Associates to hire me. If I am hired, I understand that pursuant to Colorado Statute either Palski & Associates or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Palski & Associates has the authority to make any assurance to the contrary. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal. I attest that I 1.) understand the above terms and conditions above and 2.) I authorize Palski & Associates to contact references provided for employment reference checks and 3.) by submitting this application I agree to the terms and conditions set forth in this application. Agree & Submit Application
