Personal Information Name *
I am applying for the position of Driver Driver's Helper Monitor Mechanic Wheelchair Van Driver Stretcher Vehicle Driver Other Address
* Employment History
Please provide the following requested information regarding your employment history: Include military service assignments and volunteer activities. You may exclude organization names that include race, color, religion, gender, national origin, ancestry, age, disability or other protected status.
Current or Most Recent Employer Are you currently employed? Reason for Leaving Terminated Promoted Resigned Laid Off Currently Employed May we contact? Responsibilities and Duties 2nd Previous Employer Reason for Leaving Terminated Promoted Resigned Laid Off Currently Employed May we contact? Responsibilities and Duties 3rd Previous Employer Reason for Leaving Terminated Promoted Resigned Laid Off Currently Employed May we contact? Responsibilities and Duties Voluntary Self-Identification of Gender, Ethnicity/Race, Veteran Status, and Disability
Because we do business with the U.S. Government, we must reach out to, hire, and provide equal opportunity to qualified individuals. To help us measure how we are doing, we ask you provide us with information about your race, gender, veteran status and if you have, or have had, a disability. As part of this procedure we are going to invite you to complete the following:
*Voluntary Self Identification of Gender, Ethnicity/Race
*Voluntary Self Identification of Veteran Status
*Voluntary Self Identification of Disability
Any answers you give will be kept private and will not be used against you in any way. You are not required to disclose any of this information and completion of this section is entirely voluntary.
Invitation to Self-Identify Gender and Race/Ethnicity
Express Medical Transporters is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite applicants and employees to voluntarily self-identify their gender, race and ethnicity. Submission of this information is strictly voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provision of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. This information will be maintained separately from your application for employment. If you do not wish to self-identify at this time, you may do so in the future by submitting this form. Failure to provide the following information will not subject you to any adverse action or treatment. Express Medical Transporters is an Equal Opportunity/Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.
Gender * Ethnicity/Race *
Hispanic or Latino: a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino): 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 (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino): all persons who identify with more than one of the above five races.
I decline to identify.
Invitation to Self-Identify Protected Veteran Status
Express Medical Transporters is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, 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 as follows:
A “disabled veteran” is one of the following:
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
A person who was discharged or released from active duty because of a service-connected disability. A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service. An “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. An “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 USERRA – 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 Veterans’ 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 OFCCP, or enforcing the Americans with Disabilities Act, may be informed.
Protected Veteran Status * Invitation for Voluntary Self-Identification 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. Form CC-305;
OMB Control Number 1250-0005
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. 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.