NEO A&M Employment Appication Revised 07.01.145
NORTHEASTERN OKLAHOMA A&M COLLEGE - 200 I. STREET NE - MIAMI, OK 74354-6497
Memorandum for: Applicants
Voluntary Request for EEO Information
This information is requested of all applicants on a voluntary basis. This company is a government contractor. As
a result of this coverage, we must comply with Federal and State Equal Employment Opportunity record keeping
and reporting requirements. To respond to these obligations, we must request the following information. PLEASE
NOTE: Submission of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse
action. The information you give us will be kept CONFIDENTIAL and away from your employment application.
The information may only be used in accordance with the provisions of applicable laws, executive orders and
regulations, including those that require the information to be summarized and reported to the federal government
Name: Job Applied for: ______________________________
I decline this opportunity respond to the questions listed below:
GENDER
Male Female
RACE/ETHNICITY - PLEASE CHOOSE ONE OF THE FOLLOWING:
American Indian or Alaskan Native: A person having origins in any of the peoples of North and South America (including Central America), and who
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.
Black or African American: A person having origins in any of the black racial groups of Africa.
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of
race.
Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Two or More Races:
Are you a U.S. Citizen? Yes No
Do you wish to declare yourself as mentally or physically disabled? Yes No
(If yes, please answer below.)
Description of Disability:
Skill or procedures you use or would intend to use to perform the job in spite of the disability
Accommodation which could be made that would enable you to perform the job properly and safely:
regulations may be informed.
NEO A&M Employment Appication Revised 07.01.146
MILITARY SERVICE:
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
ADISABLED 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.
ARECENTLY 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 above and 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 IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
I AM NOT A PROTECTED VETERAN
Signature: Date:
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