/ Applicant Confidential Data Collection Form
Confidential For Statistical Use Not for Interview Purposes

Argon Medical Devices is an equal opportunity/affirmative action employer. As a federal contractor, we are required to keep records on the race, sex, and ethnicity of our applicants and to file periodic reports with the government. THIS INFORMATION WILL BE KEPT CONFIDENTIAL.

APPLICANTS: Completion of this form is voluntary and your participation is appreciated.

Name: / Gender:
F M
Mailing Address: / Telephone:
Zip Code:
Position(s) Applied for: Date:

Referral Source

Advertisement / Employee / Government Agency
Private Agency / Recruiter / Relative
Temp Agency / Walk In / Website
Name of person who referred you:

Ethnicity / Race Data

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
White (Not Hispanic Latino): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
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 peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaskan Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and 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 five races.
Identify:

Disabled Status I am an individual with a disability.
(A person who has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment.)

Describe any accommodation(s), if needed, to perform the job:

Veteran Status

ARE YOU A U.S. VETERAN? Yes No If yes, please complete the following:

This form is an invitation, requested on a voluntary basis, which will be kept confidential for the purposes of allowing self-identification as a covered veteran eligible to receive benefits under the law as proscribed under the Vietnam Era Veterans Readjustment Act and the Veterans Employment Opportunities Act. Disclosure or refusal to provide this information will not subject the applicant to any adverse treatment and will be used only to support veteran’s programs in accordance with the regulations implementing 38 U.S.C. 4212.

DISABLED VETERAN
means a veteran of the U.S. military, ground, naval, or air service who is 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.
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 (61 FR 1209, 3 CFR, 1996 Comp. p159).
OTHER PROTECTED 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.
RECENTLY SEPARATED VETERAN / Separation Date:
means a 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.

For Administrative Use Only

JOB CODE / TITLE / HIRE DATE
APPLICATION STATUS: / Hired Interviewed No Interview Offer Rejected
To ensure confidentiality of this information, please email to or return this form directly to:
Argon Medical Devices, Inc. | Human Resources | 1445 Flat Creek Road | Athens, Texas 75751 USA
A04 Applicant Confidential Data Form 02OCT13.docx