Online Application

Step 1 of 6 - Voluntary Self-Identification of Disability

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 04/30/2026
Name*
First Last
Date*
MM slash DD slash YYYY
Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress toward this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, 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?

A disability is a condition that substantially limits one or more of your "major life activities." If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
- Alcohol or other substance use disorder (not currently using drugs illegally)
- Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
- Blind or low vision
- Cancer (past or present)
- Cardiovascular or heart disease
- Celiac disease
- Cerebral palsy
- Deaf or serious difficulty hearing
- Diabetes
- Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
- Epilepsy or other seizure disorder
- Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
- Intellectual or developmental disability
- Mental health conditions, for example depression, dipolar disorder, anxiety disorder, schizophrenia, PTSD
- Missing limbs or partially missing limbs
- Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
- Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
- Neurodivergence, for example, attention-deficit/hyperactivity disorder, dyslexia, dyspraxia, other learning disabilities.
- Partial or complete paralysis (any cause)
- Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
- Short stature (dwarfism)
- Traumatic brain injury
Please check one of the boxes below:*
- 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.

For more information or to request an accommodation please contact:

Human Resources
42 Cedar Street
Bangor, ME 04401
(207) 922-4600 ext. 6481 or TTY (207) 990-4730

Voluntary Self-Identification of Veterans

Definitions

This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), 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:

A “disabled veteran” is one of the following:
1. 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
2. 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.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

Self-Identification

As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. If you are not a veteran, select box 1 OR select the box(s) that apply to your veteran status.
Self Identification*
- I am not a veteran. (I did not serve in the military)
- I am NOT a protected veteran. (I served in the military but do not fall into any veteran categories listed above.)
- I choose not to identify my veteran status.
- I belong to the following classifications of protected veterans
Veteran Classification
- DISABLED VETERAN
- RECENTLY SEPARATED VETERAN
- ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN
- ARMED FORCES SERVICE MEDAL VETERAN
(Choose all that apply)
Military Discharge Date (MM/DD/YYYY):
MM slash DD slash YYYY
Your Name / Z#*
Today's Date*
MM slash DD slash YYYY

- When listing education, if you have not completed a degree program indicate how much is completed, based on fulltime attendance (i.e., 15 credit hours per semester).
- Start with your most recent position and move backward through all positions and military service for the past twenty years. You may exclude employment during high school.
- Include the month and year you began and ended each position, and the average hours/week you worked. This is vital for potentially calculating a salary quote.
- Furnish dates and explanations for each period of unemployment of one month or more.
- You may attach a resumé for supplemental information related to volunteer work, memberships, associations, etc.
- If you require more room than the space provided, please include all additional employer entries with your Resumé.
Current or Previous Employer
Employer Name*
Employer Address*
Position and Responsibilities*
Employed From*
MM slash DD slash YYYY
Employed To*
MM slash DD slash YYYY
Supervisor's Name*
First Last
Supervisor's Phone*
Average Hours Per Week*
Reason for Leaving*
May we contact this employer?*
- Yes
- No
Previous Employer 1
Employer Name
Employer Address
Position and Responsibilities
Employed From
MM slash DD slash YYYY
Employed To
MM slash DD slash YYYY
Supervisor's Name
First Last
Supervisor's Phone
Average Hours Per Week
Reason for Leaving
Previous Employer 2
Employer Name
Employer Address
Position and Responsibilities
Employed From
MM slash DD slash YYYY
Employed To
MM slash DD slash YYYY
Supervisor's Name
First Last
Supervisor's Phone
Average Hours Per Week
Reason for Leaving
Previous Employer 3
Employer Name
Employer Address
Position and Responsibilities
Employed From
MM slash DD slash YYYY
Employed To
MM slash DD slash YYYY
Supervisor's Name
First Last
Supervisor's Phone
Average Hours Per Week
Reason for Leaving
Previous Employer 4
Employer Name
Employer Address
Position and Responsibilities
Employed From
MM slash DD slash YYYY
Employed To
MM slash DD slash YYYY
Supervisor's Name
First Last
Supervisor's Phone
Average Hours Per Week
Reason for Leaving

Online Application

Step 1 of 6 - Voluntary Self-Identification of Disability

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do you know if you have a disability?

Voluntary Invitation to Self-Identify

Voluntary Self-Identification of Veterans

On-Line Application

Basic Information

General Background

Previous CHCS Employment Information

Referral & Availability

Current or Previous Employer

Previous Employer 1

Previous Employer 2

Previous Employer 3

Previous Employer 4

High School or Equivalency

Post-Secondary 1

Post-Secondary 2

Licenses & Certifications

Resume & Signature

Applicant's Statement