EEOE Survey

"*" indicates required fields

PICCOLA MANUFACTURING COMPANY EQUAL EMPLOYMENT OPPORTUNITY AND AFFIRMATIVE ACTION QUESTIONNAIRE

Piccola Manufacturing Company is an Equal Employment Opportunity Employer

Application Name:*

Position applied for:*

The information update below is required by state and federal regulations for statistical and affirmative action purposes and absolutely does not influence current or future employment decisions. Information submitted is will be kept confidential. This form is to be completed voluntarily and failure to do so will not have a negative impact on your application for employment. However, Piccola Manufacturing Company (hereinafter Piccola) must have each form returned to ensure all applicants have been given the opportunity to self-identify and in order for Piccola to able to accurately report statistics to the federal government.

Sex: (please check one):*

Male

Female

Ethnic Group: (please check one):*

Hispanic or Latino – all persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race (if you have selected this category, it is not necessary to select from the racial groups, found below)

Non-Hispanic/Latino (if this category is checked, please select from the racial groups found below)

Racial Groups: If Non-Hispanic/Latino was selected above, please check one of the below race categories:

White (Not Hispanic or Latino): all persons having origins in any of the original people of Europe, North Africa, or the Middle East

Black or African American (Not of Hispanic origin): All persons having origins in any of the black racial groups of Africa

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – any persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands

Asian (Not Hispanic or Latino) – all persons 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) - all persons having origins in any of the original peoples of North or South America, and who maintain cultural identification through tribal affiliation or community attachment

Two or More Races (Not Hispanic or Latino) – all persons who identify with more than one of the above races

Decline Self Identification: If you do not wish to self identify your gender, ethnicity or race please check the box below

I do not wish to self identify

Question/comment: HR Representative Ladonna Eschman / Ph: (502)955-8299

Thank you - This information is submitted voluntarily, will be kept confidential, will be exclusively utilized for EEO statistical gathering and compliance purposes.

VOLUNTARY VETERAN SELF-IDENTIFICATION FORM

It is the policy at Piccola Manufacturing Company to provide equal employment and advancement opportunities to all qualified individuals. To achieve this goal, Piccola Manufacturing Company is dedicated to taking affirmative action to employ and advance in employment veterans of the Vietnam Era, and other protected veterans. All personnel actions, including recruitment, hiring, training, and promoting persons in all job titles, will be administered without regard to veteran status, and all employment decisions are based solely on valid job requirements.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Information you submit about your veteran status will be kept confidential, except that (1) supervisors and managers may be informed regarding restrictions on the work or duties of veterans with disabilities, and regarding necessary accommodations; (2) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment; and (3) government officials engaged in enforcing discrimination laws may be informed. The information provided will not be used in a manner inconsistent with section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974.

Please check the applicable categories:

Special Disabled Veteran

yes

is (i) 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 the laws administered by the Department of Veterans Affairs for disability (A) rated at 30 percent or more, or (B) rated at 10 or20 percent in the case of a veteran who has been determined under Section 30 U.S.C. 3106 to have a serious employment handicap or (ii) a person who was discharged or released from active duty because of a service-connected disability

Veteran of the Vietnam Era

yes

is a person who: (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in all cases; or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service-related disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961, and May 7,1975; or (B) between August 5, 1964, and May 7, 1975 in any other location

Other Protected Veteran

yes

is 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

Newly Separated Veterans

yes

is any veteran who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veteran's discharge or release from active duty