What's your citizenship / employment eligibility?
* No answer I am a U.S. Citizen/Permanent Resident Non-citizen allowed to work for any employer Non-citizen allowed to work for current employer Non-citizen seeking work authorization I am a Canadian Citizen/Permanent Resident Other
In 150 characters or fewer, tell us what makes you unique. Try to be creative and say something that will catch our eye!
-- Education Background --
High School *
Did you graduate?
* Yes No
Did you graduate?
Other Educational Institution
Did you graduate?
-- Military Service --
Rank at Discharge
Type of Discharge
If other than honorable, explain
-- References --
Please list three professional references
Reference #1 Full Name
Reference #2 Full Name
Reference #3 Full Name
-- Work History --
Reason for Leaving
Reason for Leaving
Have you ever been convicted of or pled guilty to a criminal offense, either a felony or a misdemeanor, which has not been cleared from your record? A conviction or a guilty plea will not automatically bar employment. Please note that driving convictions such as DUI/DWI, any convictions that occurred while candidate was an adult, and convictions older than seven years are included on background reports. Report all types of offenses that you have been convicted of for review in this employment consideration.
* Yes No
If yes, explain:
-- Fair Credit Reporting Act --
As an applicant for employment or an employee of this organization, you have rights under the Fair Credit Reporting Act (FCRA). By this document, this organization discloses to you that a consumer report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment, if you are hired. If this organization obtains a consumer report about you, and if this organization considers any information in the consumer report when making an employment related decision that directly and adversely affects you, this organization will provide you with a copy of the consumer report and a summary of your rights under the FCRA before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA.
By submitting this application, I acknowledge that I have received the foregoing disclosure that this organization may obtain a consumer report as part of its pre-employment background investigation and/or during the course of my employment, if I am hired. By submitting this application, I voluntarily authorize this organization to obtain consumer reports about me and to consider the consumer report in its pre-employment background investigation and/or when making decisions during the course of my employment, if I am hired. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above. * I agree I disagree
-- Authorization & Release, Disclaimer -- Part 1
I certify that answers given herein are true and complete.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
In order that Veritas HHS may be fully informed as to my professional character, experience, credentials, and qualifications in consideration of my application for the positions noted in my application, I hereby authorize the release of such information relating to my activities as an employee of the current and former employers listed on my application. This Authorization and Release applies to information and opinions relating to my employment including, but not limited to, data regarding my dates of employment, job title and classification, compensation history, reasons for leaving, job-related knowledge and skills, level of education completed, degrees, honors or certifications received, achievements, performance, attendance, completed or pending disciplinary actions and opinions or evidence regarding general character and suitability for my position. I understand that all such information will not be disclosed to me or any other person except as authorized by law. I hereby fully waive any rights or claims I have or may have against all current and/or former employers and their agents, employees, and representatives, including records custodians, and release them from any and all liability, claims or damages of whatever kind of nature which may at any time result to me, my heirs, family, or associates from disclosure of information and opinions pursuant to this Authorization and Release. This Authorization and Release supersedes any oral or written statements to the contrary and any agreement or contract I may have previously made with my current and/or former employers and their agents, employees, and representatives, including records custodians. * I agree I disagree
-- Authorization& Release, Disclaimer -- Part 2
I agree that a electronic submission of this authorization shall be effective as my original signature.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
I understand that if offered a position with Veritas HHS I may be required to submit to a pre-employment background check and a pre-employment drug test as a condition of employment. I understand that I may also be required to submit to one or more pre- or post-employment checks as required by Veritas HHS contracts with public entities. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment checks will result in withdrawal of any employment offer or termination of employment if already employed. * I agree I disagree
The following questions are entirely optional.
To comply with government Equal Employment Opportunity / Affirmative Action reporting regulations, we are requesting (but NOT requiring) that you enter this personal data. This information will not be used in connection with any employment decisions, and will be used solely as permitted by state and federal law. Your voluntary cooperation would be appreciated.
Decline to answer Female Male
Decline to answer White (Not Hispanic) African American/Black (Not Hispanic) Hispanic Asian Pacific Islander American Indian Native Alaskan Native Hawaiian Multi-racial
Invitation for Job Applicants to Self-Identify as a U.S. Veteran
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.
Voluntary Self-Identification of Disability
Voluntary Self-Identification of Disability Form CC-305
OMB Control Number 1250-0005
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.
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:
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 boxes below:
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
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.