Self-Identification Form

In order to comply with federal equal opportunity recordkeeping and other reporting requirements, PINE asks all applicants to provide us with certain demographic information. Providing this information is strictly voluntary and will be kept confidential and separate from any resumes or other material submitted. It will not be used in determining employment at PINE. If you prefer to have a printable PDF copy of this form, click here to download that.
PINE believes all persons are entitled to equal employment opportunities and does not discriminate against its employees or applicants for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, genetic information or any other characteristic protected by law.
IMPORTANT NOTE: COMPLETION OF THIS DATA IS VOLUNTARY AND WILL NOT AFFECT EMPLOYMENT DECISIONS OR SUBJECT YOU TO ANY ADVERSE TREATMENT.
Gender*
- Male
- Female
RACE/ETHNIC DATA CLASSIFICATIONS
In completing the Race/Ethnicity portion of the form, first indicate if you so identify yourself as Hispanic or Latino. If you do so identify yourself, you should stop at that point and go on to the next section regarding veteran status. If you do not identify as Hispanic or Latino, then check the appropriate box to identify the race/ethnicity with which you do identify. If you identify with two or more races, please check the “two or more race” box, and also list the single race/ethnic group with which you most identify.
Please check ONE box below to identify yourself according to the classification definitions provided.*
- Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish Culture or origin, regardless of race.
- White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
- Black or African American (Not Hispanic or Latino): A person having origins in any of the Black racial groups of Africa.
- Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the Hawaii, Guam, Samoa, or other Pacific Islands.
- Asian (Not Hispanic or Latino): Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, including =, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam., etc.
- American Indian / Alaskan Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North or South America who maintains tribal affiliation or community attachment.
- Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above six racial/ethnic groups.
Please list the single race/ethnic group with which you most identify from the classifications provided above.
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.

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 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 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.

IMPORTANT NOTE: Disclosure of your status as a covered veteran is voluntary. Choosing not to provide this information will not subject you to any adverse treatment.
- IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OFPROTECTED VETERAN LISTED ABOVE
- I AM NOT A PROTECTED VETERAN
PINE’S Affirmative Action Plan (AAP) is a set of specific results-oriented procedures to which we, as a Company, are committed. The procedures included in the Plan, coupled with our good faith efforts are designed to ensure equal employment opportunity and compliance with Affirmative Action obligations imposed by Section 503 of the Rehabilitation Act and the Vietnam Era Veterans Readjustment Assistance Act (38 U.S.C. 4212 et.seq).
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.

Voluntary Self-Identification of Disability

Form CC-305
Page 1 of 1

OMB Control Number 1250-0005
Expires 05/31/2023
Name*
Date*
MM slash DD slash YYYY
Employee ID:

(if applicable)
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity 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: (DO NOT MARK)
- Alcohol or other substance use disorder (not currently using drugs illegally)
- Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or 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, or 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, or 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
Please check one of the boxes below:*
- Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
- No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
- I Don’t Wish To Answer
Please click the below box
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.

Step 1 of 4

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do you know if you have a disability?