Voluntary Affirmative Action I

DIAMOND DRUGS, INC.
Voluntary Affirmative
Action I
645 KOLTER DRIVE - COMMERCE PARK - INDIANA, PA
15701-3570
PHONE: 800.882.6337 FAX: 724.349.2944
Voluntary Affirmative Action Information
We consider all applicants for positions without regard to race, color, religion, sex, national origin,
citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly
protected status. We also comply with all applicable laws governing employment practices and do not
discriminate on the basis of any unlawful criteria.
To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from
application. In an effort to comply with requirement regarding government record keeping, reporting and
other legal obligations, which may apply, we invite you to complete this applicant data survey. Providing
this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse
personnel decision or action.
Your cooperation is appreciated.
Please be advised that this survey is not a part of your official application for employment. It will not be
used in any hiring decision. The information will be used and kept confidential in accordance with
applicable laws and regulations.
COMPLETION OF ANY OR ALL OF THE INFORMATION BELOW IS VOLUNTARY
Position applied for: Available_____
Not Available_____
Other position(s) considered for:___________________________
Hired: Yes / No EEO JOB CODE_____ Completed by_______
Please
do not
write in
colored
box
PLEASE PRINT
Position(s) applied for__________________________________ Date _____________
Referral Source
______Walk-in ____Government Employment Agency ___Private Employment Agency
_______Employee _____Relative _____ School ____Other ______________________
_______ Advertisement- Source_____________________________________________
Applicant Information
Name__________________________________________________________________
LAST
FIRST
MIDDLE
Address________________________________________________________________
STREET
___________ Male
CITY
STATE
ZIP
______________ Female
Please check one or more of the following Equal Employment Opportunity
Identification Groups:
____White (not of Hispanic origin)
____Black/African American (not of
Hispanic origin)
____Hispanic/Latino
____American Indian/ Alaskan Native
____Asian
____ Native Hawaiian or Other Pacific
Islander
EMPLOYMENT APPLICATION
An Equal Opportunity Employer
PERSONAL (Please Print Using Ball Point Pen).
Last Name
First
Address
Are you at least 18 years of age?
___ YES ___ NO
DATE:
Middle
Cell Phone Number
Home Telephone
City
State
Zip
Have you ever worked for
Diamond before?
Have you ever applied here
before
Have you ever been convicted
of a crime?
___ YES ___ NO
___ YES ___ NO
___ YES ___ NO
If under 18, list date of birth
Month/Day/Year ___________
_/ /
EMPLOYMENT INTERESTS AND SKILLS
Type of Employment you are Seeking:
I Am Available To Work The Following
___Full-Time
Shift: ___Day ___Night ___Any Shift
Mon
___Part-Time
Date Available for Work _________________
FROM
Total Hours Expected ___________________
TO
Tue
Wed
Thu
Fri
Sat
Sun
Wages Expected _______________________
Type of work Preferred:
Position Desired:
___Any Time
Years Of Experience In This Work:
If applying for Delivery position please provide Valid PA Driver’s License #___________________Exp. Date:________
Names of other employees in this company with whom you are acquainted:_________________________________________________
_____________________________________________________________________________________________________________
How did you know of this opening? ________________________________________________________________________________
_____________________________________________________________________________________________________________
EDUCATION
Name and address of school
Types of courses of program study
Length of course
Complete course?
Name: ____________________________________________________________ Date: ____________________
Give past employment as completely as possible, starting with you present or latest employer, including summer
employment. For any unemployed or self-employed periods, show dates and location.
Month
Day
Year
Employer’s Name &
Address, City, State and Zip
Name & Title of
Immediate Supervisor
Last Position
& Wage
Reason for
Leaving
Employer:
Address:
From
To
Phone Number:
Job Duties:_________________________________________________________________________________________
__________________________________________________________________________________________________
Month
Day
Year
Employer’s Name &
Address, City, State and Zip
Name & Title of
Immediate Supervisor
Last Position
& Wage
Reason for
Leaving
Employer:
Address:
From
To
Phone Number:
Job Duties:_________________________________________________________________________________________
__________________________________________________________________________________________________
Month
Day
From
Year
Employer’s Name &
Address, City, State and Zip
Name & Title of
Immediate Supervisor
Last Position
& Wage
Reason for
Leaving
Employer:
Address:
To
Phone Number:
Job Duties:_________________________________________________________________________________________
__________________________________________________________________________________________________
Why do you wish to leave your present employer?__________________________________________________________
__________________________________________________________________________________________________
State any additional information you think would be of interest to us in considering your application, such as skills and
abilities:___________________________________________________________________________________________
__________________________________________________________________________________________________
List 1 personal reference:
Name:_____________________ Phone: ____________________ Yrs. Acquainted: _____
List 2 professional references: Name:_____________________ Phone: ____________________ Yrs. Acquainted: ____
Name:_____________________ Phone: ____________________ Yrs. Acquainted: ____
STATEMENT OF ACCURACY AND RELEASE (Read Before Signing)
ALL APPLICANTS ARE SUBJECT TO A CRIMINAL BACKGROUND CHECK
I certify that the information contained in this application is complete and correct. I understand that incomplete or
incorrect information may be grounds for termination if I am hired. I authorize all schools, former employers,
references, arrest records and others who have information about me, to provide such information to the employer
and release all parties from any liabilities for any damage that may result from providing such information.
If employed I agree to conform to the rules, regulations, policies and procedures, of the employer and agree that my
employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at
the option of the employer or me.
This application is considered current for 1 year. If you wish to be considered for later employment, you must
renew and update your application in writing.
Signature: ____________________________________________
Date ____________________________
IF YOU HAVE THE RIGHT TO WORK,
Don’t let anyone take it away.
If you have a legal
right to work in the
United States,
there are laws to
protect you against
discrimination in
the workplace.
You should know
that –
No employer can
deny you a job or
fire you because of
your national origin
or citizenship status.
In most cases
employers cannot
require you to be a
U.S. citizen or
permanent resident
or refuse any legally
acceptable
documents.
If any of these
things have
happened to you,
you may have a
valid charge of
discrimination that
can be filed with the
OSC. Contact the
OSC for assistance
in your own
language
Call 1-800-2557688. TDD for the
hearing impaired is
1-800-237-2515.
In the Washington,
D.C., area, please
call 202-616-5594,
TDD 202-616-5525
Or write to:
U.S. Department of
Justice Office of
Special Counsel –
NYA 950
Pennsylvania Ave.,
N.W. Washington,
DC 20530
U.S. Department of
Justice Civil Rights
Division
Office of Special
Counsel for
Immigration-Related
Unfair Employment
Practices.
SI USTED TIENE DERECHO A TRABAJAR,
no deje que nadie se lo quite.
Si tiene derecho a
trabajar
legalmente en los
Estados Unidos,
existen leyes para
protegerlo contra
la discriminación
en el trabajo.
Debe saber que –
Ningún patrón
puede negarle
trabajo, ni puede
despedirlo, debido a
su país de origen o
su condición de
inmigrante.
En la mayoría de los
casos, los patrones
no pueden exigir
que usted sea
ciudadano de los
Estados Unidos o
residente
permanente o
negarse a aceptar
documentos validos
por ley.
Si se ha encontrado
en cualquiera de
estas situaciones,
usted podría tener
una queja valida de
discriminación.
Comuníquese con la
Oficina del
Consejero Especial
(OSC) de Practicas
Injustas en el
Empleo
Relacionadas a la
Condición de
Inmigrante para
obtener ayuda en
espańol.
Llame al 1-800-2557688; TDD para
personas con
problemas de
audición: 1-800237-2515. En
Washington, DC,
llame al (202) 6165594: TDD para
personas con
problemas de
audición: (202) 6165525. O escríbale a
OSC a la siguiente
dirección:
U.S. Department of
Justice Office of
Special Counsel –
NYA
950 Pennsylvania
Ave., N.W.
Washington, DC
20530
Departamento de
Justicia de los
Estados Unidos,
División de
Derechos Civiles
Oficina del
Consejero Especial
This employer will provide the Social Security Administration (SSA) a
th
This Employer Participates in E‐Verify if necessary, the Department of Homeland Security
(DHS), with in
formation from each new employee’s Form I-9 to confirm work : If the Government cannot confirm that you are authorized to work, this
employer is required to provide you written instructions and an opportunity to contact SSA and/or DHS bnst
yment.
This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Employers may not use E-Verify to pre-screen job applicants or to re-verify current employees and may not limit or influence the choice of
Security (DHS), with information from each new employee’s Form I‐9 to confirm work authorization. documents presented for use on the Form I-9.
In order to determine whether Form I-9 documentation is valid, this employer uses E-Verify’s photo screening tool to match
the photograph
appearing
on some permanent resident and employment authorization cards with the official U.S. Citizenship and
IMPORTANT: If the Government cannot confirm that you are authorized to work, this employer is required to Immigration Services’ (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has
provide you written instructions and an opportunity to contact SSA and/or DHS before taking adverse action against discriminated against you during the verification process based upon your national origin or
you, including terminating your employment. citizenship
status, please call the Office of Special Counsel at 1-800-255-7688 (TDD: 1-800-237-2515).
Employers may not use E‐Verify to pre‐screen job applicants or to re‐verify current employees and may not limit or influence the choice of documents presented for use on the Form I‐9. In order to determine whether Form I‐9 documentation is valid, this employer uses E‐Verify’s photo screening tool to match the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and Immigration Services’ (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has discriminated against you during the verification process based upon your national origin or citizenship status, please call the Office of Special Counsel at 1‐800‐255‐7688 (TDD: 1‐800‐237‐2515). NOTICE: Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United Sates.
For more information on E-Verify, please contact DHS at:
1-888-464-4218
This employer will provide the Social Security Administration (SSA) a
th
Este Empleador Participa en E‐Verify if necessary, the Department of Homeland Security
(DHS), with in
formation from each new employee’s Form I-9 to confirm work : If the Government cannot confirm that you are authorized to work, this
employer is required to provide you written instructions and an opportunity to contact SSA and/or DHS bnst
yment.
Este empleador le proporcionará a la Administración del Seguro Social (SSA), y si es necesario, al Departamento de Employers may not use E-Verify to pre-screen job applicants or to re-verify current employees and may not limit or influence the choice of
Seguridad Nacional (DHS), información obtenida del Formulario I‐9 correspondiente a cada empleado recién documents presented for use on the Form I-9.
In order
to determine whether Form I-9 documentation is valid, this employer uses E-Verify’s photo screening tool to match
contratado con el propósito de confirmar la autorización de trabajo. the photograph appearing on some permanent resident and employment authorization cards with the official U.S. Citizenship and
Immigration Services’ (USCIS) photograph. If you believe that your employer has violated its responsibilities under this program or has
IMPORTANTE: En dado caso que el gobierno no pueda confirmar si está usted autorizado para trabajar, este discriminated against you during the verification process based upon your national origin or
empleador está obligado a proporcionarle las instrucciones por escrito y darle la oportunidad a que se ponga en citizenship
status, please call the Office of Special Counsel at 1-800-255-7688 (TDD: 1-800-237-2515).
contacto con la oficina del SSA y, o el DHS antes de tomar una determinación adversa en contra suya, inclusive despedirlo. Los empleadores no pueden utilizar E‐Verify con el propósito de realizar una preselección de aspirantes a empleo o para hacer nuevas verificaciones de los empleados actuales, y no deben restringir o influenciar la selección de los documentos que sean presentados para ser utilizados en el Formulario I‐9. A fin de poder determinar si la documentación del Formulario I‐9 es valida o no, este empleador utiliza la herramienta de selección fotográfica de E‐Verify para comparar la fotografía que aparece en algunas de las tarjetas de residente y autorizaciones de empleo, con las fotografías oficiales del Servicio de Inmigración y Ciudadanía de los Estados Unidos (USCIS). Si usted cree que su empleador ha violado sus responsabilidades bajo este programa, o ha discriminado en contra suya durante el proceso de verificación debido a su lugar de origen o condición de ciudadanía, favor ponerse en contacto con la Oficina de Asesoría Especial Ilamando al 1‐800‐255‐7688 (TDD: 1‐800‐237‐2515). AVISO: La Ley Federal le exige a todos los empleadores que verifiquen la identidad y elegibilidad de empleo de toda persona contratada para trabajar en los Estados Unidos. Para mayor información sobre E-Verify, favor ponerse en contacto con la oficina del DHS Ilamando al:
1-888-464-4218
Diamond Drugs, Inc.
Voluntary Affirmative Action Information
This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment
Assistance Act of 1974 (VEVRAA), as amended, which requires Government contractors to take
affirmative action to employ and advance in employment qualified disabled veterans, recently
separated veterans, Active Duty Wartime or Campaign Badge Veterans, and Armed Forces service
medal veterans.
If you are a disabled veteran, recently separated veteran, other protected veteran, or Armed Forces
service medal veteran, we would like to include you under our affirmative action program. If you
would like to be included under the affirmative action program, please contact our Human Resources
Department.
Disabled Veteran – refers to a veteran 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, or
was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran – refers to any veteran during the three-year period beginning on the
date of such veteran’s discharge or release from active duty.
Other Protected Veteran Include Active Duty Wartime or Campaign Badge Veterans – refers to a
person 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.
Armed Forces Service Medal Veteran - refers to a person who, while serving on active duty in the
Armed Forces, participated in the United States military operation for which an Armed Forces service
medal was awarded pursuant to Executive Order 12985 (62 FR 1209).
You may inform us of your desire to benefit under the program at any time.
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
the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.
The information you submit will be kept confidential, except that supervisors and managers may be
informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary
accommodations: 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 Government officials engaged in
enforcing laws administered by OFCCP, or enforcing the Americans with Disabilities Act, may be
informed.
Diamond Drugs, Inc.’s Affirmative Action Plan is to focus on the organization’s recruiting, hiring,
training and promotion for all individuals and for all individuals to have an equal opportunity in the
placement of employment at Diamond Drugs, Inc.
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires: 1/31/2017
Page 1 of 2
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.i 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 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 not limited to:
 Blindness
 Autism
 Deafness
 Cerebral palsy
 Cancer
 HIV/AIDS
 Post-traumatic stress disorder (PTSD)
 Obsessive compulsive disorder
 Missing limbs or partially missing limbs
 Bipolar Disorder
 Major depression
 Multiple sclerosis (MS)
 Diabetes
 Schizophrenia
 Muscular dystrophy
 Epilepsy
 Impairments requiring the use of a wheelchair
 Intellectual disability (previously called mental retardation)
Please check one of the boxes below:
 YES, I HAVE A DISABILITY (OR PREVIOUSLY HAD A DISABILITY)
 NO, I DON’T HAVE A DISABILITY
 I DON’T WISH TO ANSWER
__________________________________
Your Name
________________________
Today’s Date
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires: 1/31/2017
Page 1 of 2
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.
_______________________________
i
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 Program (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.