Responsibilities and Duties
Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2020
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
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. Disabilities include, but are not limited to:
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the US. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.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.
The intent of this security form is to obtain knowledge of your background. This questionnaire will help us to determine the extent to which you meet the basic eligibility requirements for obtaining a government issued security clearance. Responding to the questions on this form is entirely VOLUNTARY. However, failure to answer will result in not being considered for a position. Your personal information is protected from unauthorized or accidental disclosure and is only seen by those persons involved in the background investigation, security clearance, and/or hiring process.
Do you currently possess a security clearance?
Have you ever been processed for a Public Trust position?
If yes, issuing agency and date acquired below:
Have you ever had a security clearance or Public Trust Position denied, suspended, or revoked?
If yes, state why below:
Have you ever had Allegiance ties outside the United States?
If Yes, explain below.
Have you ever had Foreign Influences that we should be aware of?
If Yes, explain below:
Have you ever had Foreign preferences outside the US, such as possession of a valid foreign passport?
If Yes, explain below:
Have you ever been convicted of a Sexual Offense?
Have you ever had issues with Personal Conduct?
Have you ever had Financial Considerations, such as judgments, bankruptcy?
Have you ever had problems with or ever been treated for Alcohol Consumption?
Have you ever had issues involving Improper or Illegal Drug Activity?
Have you ever had issues regarding Emotional, Mental, and/or Personality disorders?
Have you ever had any Criminal Conduct that resulted in a felony, misdemeanors, or imprisonment?
Have you ever had any Security Violations at previous job?
Have you ever had any participation in "Outside Activities", such as service/employment with a foreign country?
Have you ever had any history for misuse of Information Technology Systems?
Have you ever been terminated from a job/contract for misconduct, poor performance, undesirable allegations, etc.?
Is there any reason to believe you would not be able to obtain a position of Public Trust and/or government issued Security Clearance?
I hereby certify that all entries on this attachment are true and complete to the best of my knowledge. I understand that all information on this form is subject to verification.
Technatomy Corporation is a Certified Service Disabled Veteran Owned Small Business and an equal opportunity employer.