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Valley Electric Association, Inc.
Employment Application
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Employment Application
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Valley Electric Association, Inc. places great emphasis on customer service, teamwork, problem solving, and innovation. We look for people who exemplify these qualities and are willing to work hard for our membership. Valley Electric Association, Inc. is an equal opportunity employer. It is our policy to not discriminate in recruitment of applicants for employment nor discriminate in hiring, training, promotions, terminations and any other compensations or benefits based on race, color, religion, sex, pregnancy status, sexual orientation, gender identity or expression, national origin, ancestry, age, disability, genetic information, marital status, veteran or military status, or any other characteristic protected by law. The information furnished on this application helps to determine your qualifications for the type of work for which you have applied. It is therefore essential that every question be completed and fully answered. The completion of this application does not indicate that there are any open positions and does not obligate Valley Electric Association, Inc. to grant an interview or offer employment.
Full Name:
*
First
Middle
Last
E-mail Address
*
Home Phone
Mobile Phone
Work Phone
Position Applied For:
*
How did you learn about this vacancy?
*
Americas Job Exchange
Asian Chamber of Commerce
Employee
Friend / Relative
Health and Human Services
Jobconnect.com
Latin Chamber of Commerce
LinkedIn
Nevada Department of Employment (DETR)
Nevada Job Board
Newspaper
NRECA / Cooperative.com
NTCA Job Website
Nv Dept-Veterans Services (NDVS)
Nye County Coalition
Shade Tree Women's Shelter
UNLV
US VETS
VEA Website
Vocational Rehabilitation
Walk-in
Other Website
Name
*
First
Last
Annual Salary Desired:
Date Available:
MM slash DD slash YYYY
Are you able to perform the essential functions of this position as listed in the job description?
Yes
No
What accommodations would make it possible for you to perform this job?
Please provide a 10-year history of all your personal addresses. If additional space is required, please attach a file to this form on the page titled "Additional Documents".
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous address if less than 10 years at current address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Previous address if less than 10 years at current address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Personal Information
I understand that upon employment, proof of legal right to work in the United States and completion of an I-9 form will be required.
Are you eligible to work for any United States employer at this time?
Yes
No
If you are under the age of 18, do you have a work permit?
Yes
No
N/A
Do you have a valid driver's license?
Yes
No
State:
License Number:
Date
MM slash DD slash YYYY
Do you have a valid commercial driver's license?
Yes
No
State:
License Number:
Date
MM slash DD slash YYYY
Can you travel if the position requires it?
Yes
No
If you have ever worked under or earned degrees under another name, please list below:
Name
First
Last
Have you previously been employed by Valley Electric Association or another electric cooperative?
Yes
No
Please indicate position, department, and dates:
Do you have any relatives employed at Valley Electric Association?
Yes
No
Name of Relative(s):
Education and Training
Indicate the level of education completed
Do you have a high school diploma or equivalent (e.g. GED)?
*
High School Diploma
Equivalency (e.g. HSED or GED)
None
High School:
Location:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
GPA:
Equivalency Program:
Location:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
GPA:
Secondary Education Type (e.g. Vocational, Trade, College, University):
Name
First
Last
Location:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
GPA:
Major and Minor:
Did you graduate?
Yes
No
Degree Earned:
Secondary Education Type (e.g. Vocational, Trade, College, University):
Name
First
Last
Location:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
GPA:
Major and Minor:
Did you graduate?
Yes
No
Degree Earned:
Secondary Education Type (e.g. Vocational, Trade, College, University):
Name
First
Last
Location:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
GPA:
Major and Minor:
Did you graduate?
Yes
No
Degree Earned:
Professional certifications and licenses (such as CPA, NASD series 6):
Computer Skills (software programs, hardware, operating systems):
Other skills or experience that are pertinent to the job applied for:
Employment History
This section must be completed even if your resume is attached. Please provide a 10-year employment history, if applicable. You must provide an explanation of any gaps in employment in the "Reason for Leaving" textbox. If additional space is required, please attach a file to this form on the page title "Additional Documents".
If you are currently employed, may we contact your employer?
Yes
No
Employer:
Employed From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Contact Number:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name:
Supervisor's Job Title:
Your Job Title:
Your Duties:
Reason for leaving:
Employer:
Employed From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Contact Number:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name:
Supervisor's Job Title:
Your Job Title:
Your Duties:
Reason for Leaving:
Employer:
Employed From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Contact Number:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name:
Supervisor's Job Title:
Your Job Title:
Your Duties:
Reason for Leaving:
Employer
Employed From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Contact Number:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name:
Supervisor's Job Title:
Your Job Title:
Your Duties:
Reason for Leaving:
Employer:
Employed From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Contact Number:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Supervisor's Name:
Supervisor's Job Title:
Your Job Title:
Your Duties:
Reason for Leaving:
Professional References
Please list only references that we may contact at this time.
Name
First
Last
Title:
Company:
Work Phone
Home Phone
Name
First
Last
Title:
Company:
Work Phone:
Home Phone:
Name
First
Last
Title:
Company
Work Phone:
Home Phone:
Additional Documents
Cover Letter, Résumé, and Additional Documents
Drop files here or
Select files
Max. file size: 256 MB.
Equal Employment Opportunity is The Law
Private Employers, State and Local Governments, Educational Institutions, Employment Agencies and Labor Organizations
Applicants to and employees of most private employers, state and local governments, educational institutions, employment agencies and labor organizations are protected under Federal law from discrimination on the following bases:
Race, color, religion, sex, national origin
Title VII of the Civil Rights Act of 1964, as amended, protects applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy), or national origin. Religious discrimination includes failing to reasonably accommodate an employee's religious practices where the accommodation does not impose undue hardship.
Disability
Title I and Title V of the Americans with Disabilities Act of 1990, as amended, protect qualified individuals from discrimination on the basis of disability in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. Disability discrimination includes not making reasonable accommodation to the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or employee, barring undue hardship.
Age
The Age Discrimination in Employment Act of 1967, as amended, protects applicants and employees 40 years of age or older from discrimination based on age in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment.
Sex (Wages)
In addition to sex discrimination prohibited by Title VII of the Civil Rights Act, as amended, the Equal Pay Act of 1963, as amended, prohibits sex discrimination in the payment of wages to women and men performing substantially equal work, in jobs that require equal skill, effort, and responsibility, under similar working conditions, in the same establishment.
Genetics
Title II of the Genetic Information Nondiscrimination Act of 2008 protects applicants and employees from discrimination based on genetic information in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. GINA also restricts employers' acquisition of genetic information and strictly limits disclosure of genetic information. Genetic information includes information about genetic tests of applicants, employees, or their family members; the manifestation of diseases or disorders in family members (family medical history); and requests for or receipt of genetic services by applicants, employees, or their family members.
Retaliation
All of these Federal laws prohibit covered entities from retaliating against a person who files a charge of discrimination, participates in a discrimination proceeding, or otherwise opposes an unlawful employment practice.
What to do if you believe discrimination has occurred
There are strict time limits for filing charges of employment discrimination. To preserve the ability of EEOC to act on your behalf and to protect your right to file a private lawsuit, should you ultimately need to, you should contact EEOC promptly when discrimination is suspected: The U.S. Equal Employment Opportunity Commission (EEOC), 1-800-669-4000 (toll-free) or 1-800-669-6820 (toll-free TTY number for individuals with hearing impairments). EEOC field office information is available at www.eeoc.gov or in most telephone directories in the U.S. Government or Federal Government section. Additional information about EEOC, including information about charge filing, is available at www.eeoc.gov.
Employers Holding Federal Contracts or Subcontracts
Applicants to and employees of companies with a Federal government contract or subcontract are protected under Federal law from discrimination on the following bases:
Race, color, religion, sex, national origin
Executive Order 11246, as amended, prohibits job discrimination on the basis of race, color, religion, sex, or national origin, and requires affirmative action to ensure equality of opportunity in all aspects of employment.
Individuals with disabilities
Section 503 of the Rehabilitation Act of 1973, as amended, protects qualified individuals from discrimination on the basis of disability in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment. Disability discrimination includes not making reasonable accommodation to the known physical or mental limitations of an otherwise qualified individual with a disability who is an applicant or employee, barring undue hardship. Section 503 also requires that Federal contractors take affirmative action to employ and advance in employment qualified individuals with disabilities at all levels of employment, including the executive level.
Disabled, recently separated, other protected, and Armed Forces service medal Veterans
The Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212, prohibits job discrimination and requires affirmative action to employ and advance in employment disabled veterans, recently separated veterans (within three years of discharge or release from active duty), other protected veterans (veterans who served during a war or in a campaign or expedition for which a campaign badge has been authorized), and Armed Forces service medal veterans (veterans who, while on active duty, participated in a U.S. military operation for which an Armed Forces services medal was awarded).
Retaliation
Retaliation is prohibited against a person who files a complaint of discrimination, participates in an OFCCP proceeding, or otherwise opposes discrimination under these Federal laws. Any person who believes a contractor has violated its nondiscrimination or affirmative action obligations under the authorities above should contact immediately: The Office of Federal Contract Compliance Programs (OFCCP), U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210, 1-800-397-6251 (toll-free) or (202) 693-1337 (TTY). OFCCP may also be contacted by e-mail at OFCCP-Public@dol.gov, or by calling an OFCCP regional or district office, listed in most telephone directories under U.S. Government, Department of Labor.
Programs or Activities Receiving Federal Financial Assistance
Race, color, national origin, sex
In addition to the protections of Title VII of the Civil Rights Acts of 1964, as amended, Title VI of the Civil Rights Act of 1964, as amended, prohibits discrimination on the basis of race, color, or national origin in programs or activities receiving Federal financial assistance. Employment discrimination is covered by Title VI if the primary objective of the financial assistance is provision of employment, or where employment discrimination causes or may cause discrimination in providing services under such programs. Title IX of the Education Amendments of 1972 prohibits employment discrimination on the basis of sex in educational programs or activities which receive Federal financial assistance.
Individuals with disabilities
Section 504 of the Rehabilitation Act of 1973, as amended, prohibits employment discrimination on the basis of disability in any program or activity which receives Federal financial assistance. Discrimination is prohibited in all aspects of employment against persons with disabilities who, with or without reasonable accommodation, can perform the essential functions of the job. If you believe you have been discriminated against in a program of any institution which receives Federal financial assistance, you should immediately contact the Federal agency providing such assistance.
Consent
*
I agree to have the below be my electronic signature
Electronic Signature
Affirmative Action: Voluntary Self-Identification Form
Valley Electric Association, Inc. is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program. In extending this invitation you are advised that responses will remain confidential within the Human Resources Department and responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity and we actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment. Please complete the information requested below. Thank you for your cooperation.
Gender
Male
Female
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race:
White (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Asian (not Hispanic or Latino)
Native Hawaiian or other Pacific Islander (not Hispanic or Latino)
Two or more races
Electronic Signature:
*
Voluntary Self-Identification of Disability
Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2020 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 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 check one of the options below:
Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer
Name
*
First
Last
Today's Date:
*
MM slash DD slash YYYY
Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2020 Page 2 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 formate, using a sign language interpreter, or using specialized equipment. iSection 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 http://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.
Invitation to Self-Identify for Protected Veterans
Valley Electric Association, Inc. 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 Veteran 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 the information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
I belong to the following classifications of protected veterans (choose all that apply):
I identify as one or more of the classifications of protected Veteran listed above.
I am not a 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 the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restriction 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. A written copy of the Affirmative Action Program for Veterans and Individuals with Disabilities is available for inspection by any employee or applicant for employment, during normal business hours 8:00am to 5:00pm, in the Human Resources office. Interested persons should contact Human Resources, at (775) 727-5312, for assistance.
Electronic Signature:
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Pre-Employment Drug Testing and Background Investigation
Background Investigation
In connection with my application for employment with Valley Electric Association, Inc., I understand that investigative inquiries may be obtained on myself by a consumer reporting agency, and that any such report will be used solely for employment-related purposes. I understand that the nature and scope of this investigation will include a number of sources including, but not limited to, consumer credit, criminal history, motor vehicle reports and other similar reports. These reports will include information as to my character, general reputation, personal characteristics, mode of living, and work habits. Information relating to my performance and experience, along with reasons for termination of past employment from previous employers, may also be obtained. Further, I understand that you will be requesting information from various Federal, State, County and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, education, and other experiences.
Drug Testing
I understand that as an applicant and/or prospective employee of Valley Electric Association, Inc. that I will be drug tested. I recognize that any offer of employment to me by Valley Electric Association, Inc. is conditional upon my successful completion of a drug test to confirm that there are no illegal or unauthorized substances in my system. I hereby voluntarily consent to: Providing an unadulterated sample of my urine or hair to the designated testing provider for the purpose of drug testing for the presence of illegal or unauthorized substances in my system. Allowing the results of the screening performed by the designated testing provider to be reported to Valley Electric Association, Inc. Having the information as to whether I have passed or failed the drug testing to be communicated to Valley Electric Association, Inc.'s Human Resources Department or Legal Department. In consideration of Valley Electric Association, Inc.'s review of my application for employment, I hereby release any individual and/or entity from all claims or liabilities that might arise from the background investigation and the drug test or the disclosure of its results, including claims under any federal, state, or local civil rights law and any claims for defamation or invasion of privacy.
Electronic Signature:
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Affidavits
Please read all of the affidavits below before signing this application.
Non-binding Application and Interview Process
I understand that this application will be reviewed, but nothing in this application or any other documents or in the employment evaluation process shall be construed as either an offer or contract of employment, or an obligation on the part of Valley Electric Association, Inc. to provide any benefit to me.
Employment-At-Will
I understand that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either Valley Electric Association, Inc. or myself.
Authorization for Background Investigation
I authorize investigation of these statements. This investigation may include employment history, reasons for leaving previous employers, criminal record, credit record, driving record, social security number investigation, and degree/certificate verification. I release all parties from any and all liability or claims for any damage whatsoever that may result therefrom. This means that Valley Electric Association, Inc. is authorized to contact the schools, references and prior employers listed above, and is further authorized to contact any third party referred by these sources.
Testament to Accuracy
By signing below, I hereby declare that my statements on this application and on my resume or documents provided by me to Valley Electric Association, Inc. are true, correct, and without omissions. I acknowledge and agree that providing any false information may result in a decision not to hire me, or if hired, may result in the termination of my employment at any time during the period of my employment. This application shall be considered active for a period of time not to exceed 90 days.
Electronic Signature:
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