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CareerSource Gulf Coast Registration


REGISTRANT INFORMATION

 

 
 
 
 
 
 
   

 
Phone:   - -
   
Date of Birth:   / /
 
Last 4 of SSN:  
 

EDUCATION LEVEL

Check all boxes that apply

 

 
 
grade completed
 
 
years completed
 
 

VETERAN / MILITARY DEPENDENT 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:

• 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 the Uniformed Services Employment and Reemployment Rights Act (USERRA). 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.

 

 Protected veteran

 

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 not inconsistent with VEVRAA.

 

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.

 

 Veteran status

 

 Campaign veteran

 

 Disabled veteran

 
 

 Recently separated

 
 
   
 

 Dependent of an active duty service member?

 

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

 

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

 

How do I know if I 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:

• Blindness

• Deafness

• Cancer

• Diabetes

• Epilepsy

• Autism

• Cerebral palsy

• HIV/AIDS

• Schizophrenia

• Muscular dystrophy

• Bipolar disorder

• Major depression

• Multiple sclerosis (MS)

• Missing limbs or partially missing limbs

• Post-traumatic stress disorder (PTSD)

• Obsessive compulsive disorder

• Impairments requiring the use of a wheelchair

• Intellectual disability (previously called mental retardation)

 

 Please select a status

 

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

 

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

 

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.


DEMOGRAPHIC INFORMATION

The information requested below is used by Career Source Florida only to maintain records required of employers doing business with the federal government. YOU DO NOT HAVE TO ANSWER THESE QUESTIONS TO BE CONSIDERED FOR EMPLOYMENT WITH Career Source Florida. If you do choose to answer these questions, any information supplied by you on this voluntary self-identification form will not affect your employment opportunities with Career Source Florida, which is an equal employment opportunity employer.

 

 Race / ethnicity

 

 Gender


PRIVACY STATEMENT

Employ Florida and CareerSource Gulf Coast is strongly committed to maintaining the privacy of confidential information provided by its customers. Personally identifying information is kept in a secure, encrypted database. Please note that disclosure of your social security number is voluntary. It is requested however, pursuant to Section 119.071(5)(a), Florida Statutes for the administration of WIOA programs, and will be used in assessing and reporting performance and accountability to the federal government.

 

By submitting this form, you are agreeing to registration in Employ Florida, the state of Florida's job matching system used by CareerSource Gulf Coast. Once your registration is completed, CareerSource Gulf Coast will email you a password that you have the option to change.

 

 
 
 

 

Job Center
Phone: (850) 872-4340
Fax: (850) 872-4346

625 Highway 231
Panama City, FL 32405

 

Board Office
Phone: (850) 913-3285
Fax: (850) 913-3269

5230 W. Highway 98
Panama City, FL 32401

 

CareerSource Gulf Coast

CareerSource Gulf Coast is an equal employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers on this website may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.

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