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
Disabled Status
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.
(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.)
APPLICANTS: Completion of this form is voluntary and your participation is appreciated.
Name:
I am an individual with a disability.
Describe any accommodation(s), if needed, to perform the job:
Gender:
F
Mailing Address:
M
Telephone:
Veteran Status
Zip Code:
Position(s) Applied for:
Date:
Referral Source
Advertisement
Employee
Government Agency
Private Agency
Temp Agency
Recruiter
Walk In
Relative
Website
Name of person who referred you:
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
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
ARE YOU A U.S. VETERAN?
(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.
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
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
the above five races.
Identify:
(Not Hispanic or Latino): All persons who identify with more than one of
APPLICATION STATUS:
Hired
Interviewed
No Interview
Offer Rejected
To ensure confidentiality of this information, please email to janice.russell@argonmedical.com or return this form directly to:
Argon Medical Devices, Inc. | Human Resources | 1445 Flat Creek Road | Athens, Texas 75751 USA
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