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Are you authorized to work in the United States?
I am authorized to work in the United States for any employer
I am authorized to work in the United States for my present employer only
I require sponsorship to work in the United States
My status to work in the United States is unknown
Have you ever been employed by Chemonics International before? If yes, provide the dates and position(s), in the second field to the right.
Prev. Employee Details:
Are you available for full time or part-time work?
On what date would you be available to work?
Two weeks’ notice
Three weeks' notice
Four weeks’ notice
More than four weeks’ notice
Are you now or do you see in the foreseeable future to become a board member of any private company or non-profit organizations? If yes, provide the name of the company or non-profit in the second field below.
Board Member Company:
How did you hear about us?
Boxwood Technology, Inc.
Career Fair (please specify)
Chemonics Careers Website
Chemonics social media
Event: at Chemonics (please specify)
Event: other (please specify)
Friends or family member
Job Board: Devex
Job Board: Other (please specify)
Job Board: Professional Diversity Network
Other (Please Specify)
Teacher or Professor
Specify Source or Referral:
* Put in N/A in the above field if not applicable.
School / Social Media:
* Put in N/A in the above field if not applicable.
Employment History - Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.:
References - List three references. Do not include relatives or supervisors previously stated above.:
Did you serve in the U.S. Armed Forces? If yes, provide what branch, where, and your dates of service; in the second field below?
U.S. Service Member:
EU Recruiting Data Privacy Notice
The protection of your personal data is important to Chemonics. If you are located in the EU, please read our EU Recruiting Data Privacy Notice to learn how we process your personal data.
This concludes the application information.
Voluntary Equal Opportunity Questionnaire
Applicants are considered for all positions at Chemonics, and employees are treated without regard to race, religion, sex, national origin, age, marital or veteran status, medical condition, or handicap. As an employer/government contractor, we comply with government regulations and affirmative action responsibilities.
The government requires periodic reports on the sex, ethnicity, handicapped, and veteran status of job applicants. This data is for analysis and affirmative action only. Your submission of this information is entirely voluntary.
Choose Not to Disclose
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
Choose Not to Disclose
Not Applicable (Non-U.S.)
Voluntary Veterans Status
This employer 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:Show citation box 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.
I am not a protected veteran
Recently Separated Veteran
Active Wartime or Campaign Badge Veteran
Armed Forces Service Medal Veteran
I am a protected veteran, but choose not to self-identify by classification
Choose Not to Disclose
If you are a disabled veteran, it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services, or other accommodations. This information will assist us in making reasonable accommodations for your disability.
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 consistent 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 the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
Voluntary cc305 Form
Candidate Individual with disabilities:
Voluntary Self-Identification of Disability
OMB Control Number
Page 1 of 1
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 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.
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 • Deaf or hard of hearing • Missing limbs or partially missing limbs • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS • Depression or anxiety • Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS) • Blind or low vision • Diabetes • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression • Cancer • Epilepsy • Cardiovascular or heart disease • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome • Celiac disease • Intellectual disability • Cerebral palsy Please Select one of the options 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
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.
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Job Title: _______________
Date of Hire: _______________