Employment Opportunity Data

Chipton-Ross is required to collect this information for equal opportunity employment purposes, however completion of this form is entirely voluntary. All information will remain confidential and will not affect decisions of employment.

Name:

Email Address:
Gender:
Race/Ethnicity: {Check all that apply}



An individual with a disability is a person who has an impairment which substantially limits one or more of such person’s major life activities, or who has a record of such impairment.
Government contractors must take affirmative action to employ and advance certain qualified individuals subject to the Rehabilitation Act of 1973 and the Vietnam Era Veterans Readjustment Act of 1974. Completion of the following information is voluntary, and will assist us in proper placement and reasonable accommodation. If you wish to be identified as qualifying for such placement or accommodation, please check where applicable:
A “disabled veteran” means a veteran who served on active duty in the U.S. military ground, naval, or air service: (1) is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs, or (2) was discharged or released from active duty because of a service-connected disability.
Means a person who: (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released therefrom with other than a dishonorable discharge, 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; or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service 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 any other location.
Means any recently separated veteran (within 36 months from discharge or release from active duty) who served on active duty in the U.S. military, ground, naval or air service.
Means veterans 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 awarded.
Veterans who, while serving on active duty in the Armed Forces, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. For those with Internet access, the information required to make this determination is available at http://www.opm.gov/veterans/html/vgmedal2.htm. A replica of that list is enclosed with the annual VETS-100 mailing. A copy of the list also may be obtained by sending an e-mail to: othervets@vets100.com or by calling (703) 461-2460 and requesting that a copy of the list be mailed to you.