Louis Strom Daniel

RLD Certified

• ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? YES NO
• ARE YOU 18 YEARS OR OLDER? YES NO
• HAVE YOU EVER WORKED FOR THIS EMPLOYER? YES NO
• IF YES, WRITE THE START AND END DATES:
• HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES NO
• IF YES, PLEASE EXPLAIN:
• EMPLOYEE REFERRAL? :
• DO YOU HAVE A VALID, UNEXPIRED DRIVER’S LICENSE? YES NO

• ARE YOU A VETERAN? YES NO
• BRANCH:
• RANK AT DISCHARGE:
• FROM: TO:
• TYPE OF DISCHARGE:
• IF NOT HONORABLE, PLEASE EXPLAIN:

• We are a federal contractor or subcontractor required by law to provide equal employment opportunities 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:
• 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)
• Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
• Partial or complete paralysis (any cause)
• Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
• Short stature (dwarfism)
• Traumatic brain injury
• Yes, I have a disability or have a history/record of having a disability.
• No, I don’t have a disability or have a history/record of having a disability.
• I don’t wish to answer.

• This company is subject to Executive Order 11246, as amended, which requires Federal contractors to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. Therefore, we are requesting information about the race and gender of our applicants to comply with government reporting requirements and ensure equal employment opportunities.
• This company is also 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 veterans in the following classifications: 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 under https://www.federalregister.gov/articles/1996/01/18/96-622/establishing-the-armed-forces-service-medal, 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 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 to measure the effectiveness of the outreach and positive recruitment efforts we undertake under VEVRAA.
• GENDER:
• Female
• Male
• I choose not to identify my gender
• RACE/ETHNICITY:
• American Indian or Alaskan Native (Not Hispanic or Latino)
• Black or African American (Not Hispanic or Latino)
• Hispanic or Latino
• Asian (Not Hispanic or Latino)
• White (Not Hispanic or Latino)
• Native Hawaiian or Pacific Islander (Not Hispanic or Latino)
• Two or More Races (Not Hispanic or Latino)
• I choose not to identify my race/ethnicity
• 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.
• Disabled Veteran
• 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
• War/Campaign/Expedition Veteran
• 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
• 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
• Recently Separated Veteran
• 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.
• I am not a veteran
• I do not wish to self-identify