Applicants are considered without regard to race, color, national origin, ancestry, age, gender, sexual orientation, religion, disability, military status, genetic information, criminal record, or any other legally protected status. Please type or print and provide complete answers. If you feel that any question or request may violate your rights, do not answer it.

Date of application: On what date will you be available to begin working?
Position you are applying for: (check one) Full-Time Part-Time Per Diem

Last Name: First Name: M.I.

Street Address: City: State: Zip Code:
Driver's license number: State:
E-mail: Telephone: Other number(s) you can be reached at:
What is your schedule preference? (check one) Days Evenings Nights   
Are you available on weekends?
Will you work any shift?

Have you ever applied for employment with Medstar or Critical Systems Inc.? Yes No

High School

Name and location of high school:
Course of study: Number of years completed: Did you graduate? Yes No

College

Name and location of college:
Course of study: Number of years completed: Did you graduate? Yes No

Trade School / Other

Name and location of school:
Course of study: Number of years completed: Did you graduate? Yes No

Emergency Medical Certifications:

EMT# State: Level: (check all that apply) Basic   Advanced   Paramedic

Please list all employers, past and present, starting with the most recent. Attach additional pages if necessary.

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

Employer: Address: Phone:
Name of your supervisor: May we contact this person? Yes No    Your job title:
Your job description:
Dates of employment Starting: Ending:
Reason for leaving:

List professional, trade, or civic activities and offices held:

Provide any additional information which you feel may be helpful to Critical Systems Inc. in considering your application. You may also include any hobbies / interests:

References

Please list three or more people who are not related to you who you have known for at least one year. (These people may be contacted by Critical Systems Inc.)

Name and Address	Phone Number	Occupation

Critical Systems is a government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, 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:

Disabled veteran	A veteran of the U.S. military, ground, naval, or air service (1) 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 Department of Veterans Affairs, or (2) who was discharged or released from active duty because of such a service-connected disability
Recently separated veteran	Recently separated veteran A veteran who was discharged or released from active duty in the U.S. military within the last three (3) years
Recently separated veteran	Armed Forces Service Medal Veteran A veteran who, while on active duty, participated in a U.S. military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985
Active Duty Wartime or Campaign Badge Veteran	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 laws administered by the U.S. Department of Defense

Please check one of the boxes below: I identify as one or more of the classifications of Protected Veteran listed above I am not a Protected Veteran I choose not to Self-Identify

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 VEVRAA, as amended.

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.

Autism Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS Blind or low vision Cancer Cardiovascular or heart disease Celiac disease Cerebral palsy	Deaf or hard of hearing Depression or anxiety Diabetes Epilepsy Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome Intellectual disability	Missing limbs or partially missing limbs Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS) Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major
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

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