As an applicant for employment with Midwest Maintenance, I understand the following:
This application will remain on active file for 60 days. If I am hired within this period, it will become part of my personnel file.
Any misrepresentation, falsification, or significant omissions of information will be cause for rejection of my application or for subsequent discipline up to and
including my dismissal from employment if discovered at a later date.
I hereby agree to submit to any lawful drug or background check that may be required as a condition of employment or continued employment, and understand
that the refusal to submit to such testing during the course of my employment may result in disciplinary action, up to and including discharge.
I authorize and consent to my current and prior employers, educational institutions, consumer reporting agencies and persons or organizations named In this application (or
accompanying resume)to release any information to Midwest Maintenance Company, and I release them from liability from damage in providing information that may
require to make an employment decision.
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.
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
Disabilities include, but are not limited to:
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 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.
1.Midwest Maintenance 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:
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), tollfree, at 1-866-4-USA-DOL.
2.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
As a Government contractor subject to VEVRAA, we are required to submit a report
to the United States Department of Labor each year identifying the number of our
employees belonging to each specified “protected veteran” category. If you believe you
belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below:
If you are a disabled veteran it would assist us if you tell us whether there are
accommodations we could make that would enable you to perform the essential functions
of the job, including special equipment, changes in the physical layout of the job, changes
in the way the job is customarily performed, provision of personal assistance services or
other accommodations. This information will assist us in making reasonable
accommodations for your disability.
3.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.
4.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.