Apply for Tack Truck Driver - CDL

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Tack Truck Driver - CDL
ID:1052-VB
Location:Vero Beach, Fl
Department:Paving
Resume
Resume:
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Contact Information
* First Name:
Middle Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Application Information
* Source:
Source - Select from the list above how you heard about this job?
Other:
If an employee referred you, enter their full name. If source who referred you is not on our list, enter source above.
Opt-In Confirmation
I authorize recruiters from OHLA USA to send text messages from 8446995191 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
1. Application for Employment - All Applicants
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

Yes   No

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

Reference 2

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company 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 the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

2. Application for Employment - All Applicants
* HAVE YOU EVER BEEN TERMINATED OR ASKED TO RESIGN YOUR JOB?
¿ALGUNA VEZ HA SIDO DESPEDIDO O SE LE HA PEDIDO RENUNCIAR A SU TRABAJO?
Yes
No
If you answered yes, please explain:
Si respondió afirmativamente, por favor explique:
* HAVE YOU EVER BEEN A DEFENDANT IN A CIVIL SUIT ON AN INTENTIONAL TORT (ASSAULT, BATTERY, FALSE IMPRISONMENT, INVASION OF PRIVACY, INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS, INTENTIONAL WRONGFUL DEATH?)  

¿HA SIDO ALGUNA VEZ UN ACUSADO EN UNA DEMANDA CIVIL POR UN AGRAVIO INTENCIONAL (ASALTO, AGRESIÓN, ENCARCELAMIENTO FALSO, INVASIÓN DE LA PRIVACIDAD, INFLICACIÓN INTENCIONAL DE ANGUSTIA EMOCIONAL, MUERTE POR NEGLIGENCIA INTENCIONAL?)
Yes
No
If yes, please provide date and details of each:
Si respondió afirmativamente, por favor proporcione la fecha y los detallas de cada uno:
* HAVE YOU EVER PLED GUILTY OR "NO CONTEST" TO A CRIME, BEEN CONVICTED OF A CRIME, HAD ADJUDICATION WITHHELD, PROSECUTION DEFERRED OR DO YOU HAVE ANY CRIMINAL CHARGES PENDING?
Note: Answering "Yes" to this question does not constitute an automatic bar to employment.  Only those crimes which are substantially related to the position you are seeking will be considered.

¿ALGUNA VEZ SE HA DECLARADO CULPABLE O "NO CONCURSO" DE UN DELITO, HA SIDO CONDENADO POR UN DELITO, LE HA RETENIDO LA ADJUDICACIÓN, EL PROCESO APLASTADO O TIENE ALGÚN CARGO PENAL PENDIENTE?
Nota: Responder "Sí" a esta pregunta no constituye una prohibición automática de empleo. Sólo se considerarán aquellos delitos que estén sustancialmente relacionados con el puesto que busca.
Yes
No
If yes, please provide date and details of each:
Si respondió afirmativamente, por favor proporcione la fecha y los detallas de cada uno:



PLEASE SELECT ANY AREAS BELOW YOU HAVE EXPERIENCE IN BY ADDING THE NUMBER OF YEARS OF EXPERIENCE NEXT TO EACH ITEM BELOW.  IF YOU DO NOT HAVE EXPERIENCE IN AN AREA, LEAVE BLANK.

POR FAVOR, SELECCIONE CUALQUIER ÁREA ABAJO EN LA QUE TENGA EXPERIENCIA, AÑADIENDO LA CANTIDAD DE AÑOS DE EXPERIENCIA AL LADO DE CADA ELEMENTO. SI NO TIENE EXPERIENCIA EN UN ÁREA, DÉJELA EN BLANCO.

YEARS OF EXPERIENCE /
AÑOS DE EXPERIENCIA

Asphalt Plant - Laborer:
Asphalt Plant - Operator:
Asphalt Plant - AC Tanker Operator:
Asphalt Plant - Loader Operator:
Asphalt Plant - Welder:
Asphalt Plant - Mechanic:
Asphalt Plant - Lab - QC Tech:
Construction - Laborer:
Construction - Backhoe Operator:
Construction - Bulldozer Operator:
Construction - Carpenter:
Construction - Excavator Operator:
Construction - Gradall Operator:
Construction - Loader Operator:
Construction - Maintenance Crew:
Construction - Motor Grader Operator:
Construction - Pipelayer:
MOT - Traffic Control Specialist:
Paving - Laborer:
Paving - Backhoe Operator:
Paving - Broom/Sweeper Operator:
Paving - Loader Operator:
Paving - Milling Machine Operator:
Paving - Paver Operator:
Paving - Raker / Lute Man:
Paving - Roller Operator - Rough:
Paving - Roller Operator - Finish:
Paving - Screed Operator:
Paving - Service Truck:
Paving - Skid Steer Operator:
Paving - Shuttle Buggy:
Paving - Tack Distributer:
Shop - Fuel Service Man:
Shop - Mechanic:
Shop - Mechanic Field:
Shop - Welder:
Survey - Instrument Man:
Survey - Rodman:
Truckbase - Dump Truck Driver:
Truckbase - Fuel Service Man:
Truckbase - Lowboy Driver:
Truckbase - Water Truck Driver:
Please list any other qualifications that you have which you believe should be considered  /  Por favor, indique cualquier otra cualificación que tenga y que crea que debería ser considerada:
3. Application for CDL Driver Jobs Only

***   PER FMCSA REGULATIONS, FOR POSITIONS REQUIRING A CDL, APPLICANTS ARE RQUIRED TO ANSWER ALL QUESTIONS IN FULL BELOW - READ CAREFULLY:

EMPLOYMENT HISTORY - English
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.
Start with the last or current position, including any military experience, and work backwards.  You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information as requested.
*** IMPORTANT ***
If you have not provided the required number of years in employment history as stated above, you must provide before submitting this application. *** Also, please be sure you have complete 3 years' worth of previous residency history as required by the FMCSA for all CDL drivers.



***   SEGÚN LAS REGLAS DE LA FMCSA, PARA PUESTOS QUE REQUIEREN UN CDL, ES OBLIGATORIO QUE LOS SOLICITANTES RESPONDAN A TODAS LAS PREGUNTAS EN SU TOTALIDAD A CONTINUACIÓN - LEA CON ATENCION:

HISTORIAL DE EMPLEO - Spanish
Las Regulaciones de Seguridad para Portadores Motorizados Federales (49 CFR 391.21) exigen que todos los solicitantes que deseen conducir un vehículo comercial enumeren todo empleo de los últimos (3) años. Las Regulaciones de Seguridad para Portadores Motorizados Federales (49 CFR 391.21) exigen que todos los solicitantes que deseen conducir un vehículo comercial enumeren todo empleo de los últimos (3) años.  Además, si anteriormente ha conducido un vehículo comercial, debe proporcionar un historial de empleo de siete (7) años adicionales (para un total de diez (10) años). Cualquier hueco en el empleo que exceda de un (1) mes debe ser explicado.
Comience con la última o actual posición, incluyendo cualquier experiencia militar, y trabaje hacia atrás. Se requiere que liste la dirección postal completa, incluyendo el número de calle, ciudad, estado, código postal; y complete toda otra información como se solicita.
*** IMPORTANTE ***
Si no ha proporcionado el número de años requeridos en el historial de empleo como se menciona arriba, debe proporcionarlo antes de enviar esta solicitud. *** Además, asegúrese de haber completado el historial de residencia de los últimos 3 años, como lo requiere la FMCSA para todos los conductores de CDL.


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PRE-EMPLOYMENT DRUG AND ALCOHOL QUESTIONNAIRE / CUESTIONARIO DE DROGAS Y ALCOHOL PRE-EMPLEO

* Within the last two (2) years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?

En los últimos dos (2) años, ¿ha dado positivo o se ha negado a realizar alguna prueba de drogas o alcohol previa al empleo administrada por un empleador al cual solicitó, pero no obtuvo, trabajo sensible a la seguridad?
Yes
No
If you answered yes, please list the name of the employer/s:

Si respondió si/yes, por favor liste el nombre del o de los empleador/es:
* If you answered yes, have you successfully completed the return-to-duty process?

Si respondió si/yes, ¿ha completado exitosamente el proceso de reincorporación al trabajo?
Yes
No
Does not apply / No aplica


************

DRIVER LICENSE INFORMATION / INFORMACIÓN DE LA LICENCIA DE CONDUCIR
No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years, if applicable.

Ninguna persona que opere un vehículo motorizado comercial deberá tener más de una licencia de conducir en ningún momento (49 CFR 383.21). Certifico que no tengo más de una licencia de vehículo motorizado, cuya información se lista a continuación. Incluya todas las licencias que haya tenido en los últimos 3 años, si corresponde.

* DO YOU CURRENTLY HOLD A CDL?
¿POSEE ACTUALMENTE UN CDL?
Yes
No
* DATE OF BIRTH (as required by 49 CFR 391.21 for CDL Drivers)
FECHA DE NACIMIENTO (según lo requiere el 49 CFR 391.21 para conductores de CDL)
* SOCIAL SECURITY NUMBER (as required by 49 CFR 391.21 for CDL Drivers)
NÚMERO DE SEGURO SOCIAL (según lo requiere el 49 CFR 391.21 para conductores de CDL)
* WHICH CDL CLASS DO YOU HOLD?
¿QUÉ CLASE DE CDL POSEE?
Class A
Class B
Class C
None
* Do you have an Air Brake Restriction on your CDL?
Yes - I HAVE an Air Brake restriction and CANNOT drive vehicles with Air Brakes
No - I do NOT have an Air Brake restriction and CAN drive vehicles with Air Brakes

CURRENT LICENSE

* CURRENT LICENSE - STATE
* CURRENT LICENSE - LICENSE #
* CURRENT LICENSE - TYPE/CLASS
* CURRENT LICENSE - EXPIRATION DATE
CURRENT LICENSE - ENDORSEMENTS

PREVIOUSLY HELD LICENSE 1 (if applicable)

STATE
LICENSE #
TYPE/CLASS
EXPIRATION DATE
ENDORSEMENTS

PREVIOUSLY HELD LICENSE 2 (if applicable)

STATE
LICENSE #
TYPE/CLASS
EXPIRATION DATE
ENDORSEMENTS


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DRIVING EXPERIENCE / EXPERIENCIA DE CONDUCCIÓN
Select yes/no for the type of equipment you have experience with, list number of years of experience, approximate # of miles and dates from/to.
Seleccione sí/no para el tipo de equipo con el que tiene experiencia, liste el número de años de experiencia, número aproximado de millas, y fechas de inicio/fin.

* DUMP TRUCK - Do you have experience with Dump Trucks?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* SEMI-TRACTOR - Do you have experience with Semi-Tractors?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* LIGHT TRUCK - Do you have experience with Light Trucks?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* LOWBOY TRAILER - Do you have experience with Lowboy Trailers?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* WATER TRUCK - Do you have experience with Water Trucks?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* A/C TANKER - Do you have experience with A/C Tankers?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* DISTRIBUTER TRUCK - Do you have experience with Distributer Trucks?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* SWEEPER - Do you have experience with Sweepers?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* TRACTOR & SEMI-TRAILER - Do you have experience with Tractors & Semi-Trailers?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
* TRACTOR & TWO-TRAILERS - Do you have experience with Tractors & Two-Trailers?
Yes
No
Number of years of experience / Número de años de experiencia:
Approximate # of miles (total):
From:
To:
OTHER - Do you have experience with OTHER equipment?
¿Tiene experiencia con OTRO equipo?
Yes
No
If so, list type of equipment you have experience with and number of years of experience.
En caso afirmativo, enumere el tipo de equipo con el que tiene experiencia y el número de años de experiencia:
List any special courses or training that will help you as a driver.
Indique cualquier curso especial o entrenamiento que le ayude como conductor.
Do you hold any safe driver awards and if so, from whom?
¿Tiene algún premio de conductor seguro y, de ser así, de parte de quién?


************

ACCIDENT RECORD FOR THE PAST 3 YEARS / REGISTRO DE ACCIDENTES DE LOS ÚLTIMOS 3 AÑOS
List all accidents for the last 3 years. /
Indique todos los accidentes de los últimos 3 años.

Complete below only if applicable.  /  Complete a continuación solo si aplica.

Date of accident (list most recent first)
Fecha del accidente (liste el más reciente primero)
Nature of accident (Head-on, rear-end, upset, etc.)
Naturaleza del accidente (Frontal, choque trasero, volcadura, etc.)
# of Fatalities
# de fatalidades
# of Injuries
# de lesiones
Chemical Spills
Derrames Químicos
Yes
No

Complete below only if applicable.  /  Complete a continuación solo si aplica.

Date of accident (list most recent first)
Fecha del accidente (liste el más reciente primero)
Nature of accident (Head-on, rear-end, upset, etc.)
Naturaleza del accidente (Frontal, choque trasero, volcadura, etc.)
# of Fatalities
# de fatalidades
# of Injuries
# de lesiones
Chemical Spills
Derrames Químicos
Yes
No
If you have more than 3 accidents to list, please provide details below.
Si tiene más de 3 accidentes para enumerar, proporcione detalles a continuación.


************

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS / CONVICCIONES Y CONFISCACIONES DE TRÁFICO DE LOS ÚLTIMOS 3 AÑOS
(Other than parking violations / Aparte de infracciones de estacionamiento)

* Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
¿Alguna vez se le ha negado una licencia, permiso o privilegio para operar un vehículo motorizado?:
Yes
No
* Has any license, permit, or privilege ever been suspended or revoked?
¿Alguna vez se le ha suspendido o revocado alguna licencia, permiso o privilegio?:
Yes
No

Complete below only if applicable.  /  Complete a continuación solo si aplica.

Date Convicted
State of Violation
Violation
Penalty (forfeited bond, collateral and/or points)
Sanción (fianza perdida, garantía y/o puntos)

Complete below only if applicable.  /  Complete a continuación solo si aplica.

Date Convicted
State of Violation
Penalty (forfeited bond, collateral and/or points)
Sanción (fianza perdida, garantía y/o puntos)
If you have more than 3 convictions/forfeitures to list, please provide details below.
Si tiene más de 3 condenas o confiscaciones que enumerar, proporcione detalles a continuación.
* *** I certify that other than what is listed above, I have not been convicted or forfeited bond or collateral on account of any violation other violation required to be listed. TYPE YOUR NAME TO SIGN BELOW.

*** Certifico que, aparte de lo que se enumera anteriormente, no he sido condenado ni he perdido una fianza o garantía debido a ninguna otra infracción que deba ser listada. ESCRIBA SU NOMBRE PARA FIRMAR A CONTINUACION.


************

CHECKLIST FOR CDL DRIVER APPLICATIONS  /  VERIFICACIÓN PARA SOLICITUDES DE CONDUCTORES DE CDL

* Did you provide 3 years' worth of previous residency history? If not, please go back and provide.

¿Proporcionó un historial de residencia de los últimos 3 años? Si no, por favor regrese y proporcione.
Yes
No
* Did you provide the correct number of years worth of employment history as required by the FMCSA regulations? If not, please go back and provide.

¿Proporcionó el número correcto de años de historial laboral según lo requerido por las regulaciones de la FMCSA? Si no, por favor regrese y proporcione.
Yes
No
** Q - CDL A or B & Tanker (N), HazMat (H), Tanker & HazMat (N) - Air Brakes (L) Restriction

First Name

Last Name

* CDL Class - Do you currently have a CDL Class A or Class B?
Class A
Class B
Neither
* Select your endorsements below:
Tanker Endorsement (N) - ONLY
HazMat Endorsement (H) - ONLY
Both - Tanker & Hazmat Endorsements (X)
No Endorsement
* Do you currently have an Air Brake (L) restriction on your driver's license?
YES - I HAVE an Air Brake restriction (L) on my driver's license.
NO - I do NOT have an Air Brake restriction (L) on my driver's license.
4. Applicant's Statement - All Applicants

APPLICANT'S STATEMENT - ENGLISH

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
THIS ORGANIZATION PARTICIPATES IN E-VERIFY.

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.

I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at any time with or without notice or reason and the Company has the same right. No one other than the President of the Company has authority to modify this relationship or make any agreement to the contrary. Any such modification or agreement must be in writing.

I understand that the Company reserves the right to require me to submit to a drug test at any time and, it also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them. I release my previous employers from any liability as a result of their disclosure of information about me to the Company. I also authorize the Company to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information.

I further understand that if employed I will be on a 90-day introductory period, and that termination for unsatisfactory performance during that period will not result in any Company responsibility for unemployment benefits. I further understand that completion of the introductory period does not confer any expectation of continued employment, and that, if employed, my employment will be for no definite period and is at will.

By signing below, I certify that all of the information that I provide on this application and in any interview will be true, complete and accurate. I understand that if I am employed and any such information is later found to be false or misleading in any respect, I will be dismissed.

I certify that I have received a written notification that the Company may obtain a consumer report or reports on me. I authorize this Company to obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my employment. I understand that the term "consumer report" includes, but is not limited to, credit checks, criminal background checks, department of motor vehicle reports, and investigative consumer reports. I further understand that the term "investigative consumer report" means a report in which information on my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with my neighbors, friends, or associates, or with other with whom I am acquainted or who may have knowledge concerning any such items of information.

*** DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THIS STATEMENT ***



DECLARACION DEL SOLICITANTE - SPANISH

SOMOS UNA COMPAÑIA CON IGUALDAD EN OPORTUNIDAD DE EMPLEO.
ESTE EMPLEADOR PARTICIPA EN E-VERIFY.

En cumplimiento con las leyes federales y estatales de igualdad de oportunidades de empleo, los solicitantes calificados son considerados para todos los puestos sin distinción de raza, color, religión, sexo, origen nacional, edad, estado civil o discapacidad no relacionada con el trabajo.

Tengo entendido que si me emplean, mi empleo no será por un período definido, sin importar el período de pago de mis salarios. Además comprendo que tengo el derecho de dar por terminado mi empleo en cualquier momento con o sin aviso o razón y la Compañía tiene el mismo derecho. Nadie, con la excepción del Presidente de la Compañía tiene la autoridad de modificar esta relación o llegar a un acuerdo de lo contrario. Cualquier modificación o acuerdo debe ser hecho por escrito.

Tengo entendido que la Compañía se reserva el derecho de requerir que yo me someta a un exámen de drogas en cualquier momento y también se reserva el derecho de requerir que yo me someta a un exámen de alcohol y/o examen médico hasta el punto permitido bajo la ley. Además entiendo que la Compañía puede ponerse en contacto con mis patrones anteriores y autorizo a los mismos que revelen a la Compañía todos los datos pertinentes a mi empleo con ellos. Yo libero a mis patrones anteriores de cualquier obligación que resulte por la revelación de información sobre mi persona a la Compañía. Además autorizo a la Compañía que provea información verdadera referente a mi empleo con ellos a mis futuros patrones y estoy de acuerdo en eximirlos de responsabilidades por proveer dicha información.

Tengo entendido que si me emplean, estaré en un período de prueba de 90 días y que la terminación de mi empleo por ejercer mi trabajo de un modo poco satisfactorio durante ese período no resultará responsabilidad de la Compañía para beneficios de desempleo. Además comprendo que al completar el período de prueba no confiere ninguna obligación de empleo continuado y que si me emplean, mi empleo no será por un período definido y sin termino fijo.

Firmando esta declaración, yo certifico que toda la información que proporciono en esta solicitud y en cualquier entrevista, es verdadera, completa y exacta. Tengo entendido que si me emplean y si más tarde encuentran que cualquier información que he suministrado es falsa o engañosa en cualquier aspecto, me pueden despedir.

Certifico que he recibido una notificación por escrito que la Compañía puede obtener un reporte del consumidor o reportes sobre mí. Yo autorizo a esta Compañía para que obtenga dicho reporte o reportes para uso en conexión con mi solicitud de empleo y por otras razones relacionadas con mi empleo. Si me emplean, esta autorización se mantendrá en archivo y servirá como autorización continua para requerir reportes del consumidor relacionado con mi empleo en cualquier momento durante mi empleo. Tengo entendido que el término “reporte del consumidor” incluye, pero no se limita a verificación de crédito, verificación de antecedentes criminales, reportes del departamento de vehículos y reportes investigativos de consumidor. Además entiendo que el término “reportes investigativos de consumidor” significa un reporte el cual da información sobre mi carácter, reputación general, características personales o modo de vivir y es obtenida a través de entrevistas personales con mis vecinos, amigos, asociados u otros que me conocen o que tengan conocimiento con referencia a cualquiera de estos artículos de información

*** NO FIRME HASTA QUE NO HAYA LEIDO ESTA DECLARACION ***


*
Type your name to sign and acknowledge you have read and understood the Applicant's Statement.   /   Escriba su nombre para firmar y reconocer que ha leído y entendido la declaración del solicitante.
* Enter today's date   /   Ingrese la fecha de hoy:
5. Voluntary Self-Identification of Disability CC-305 - All Applicants

Voluntary Self-Identification of Disability

Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 04/30/2026
Name:
Employee ID:
(if applicable)
Date:

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, 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?

A disability is a condition that substantially limits one or more of your "major life activities." If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
  • Alcohol or other substance use disorder (not currently using drugs illegally)
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
  • Blind or low vision
  • Cancer (past or present)
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or serious difficulty hearing
  • Diabetes
  • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
  • Epilepsy or other seizure disorder
  • Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
  • Intellectual or developmental disability
  • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
  • Missing limbs or partially missing limbs
  • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
  • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
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Veteran Status: (Please check all that apply)
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
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Armed Forces Service Medal Veteran
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 No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
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Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
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