Application for Employment

New Leaf, Inc. is a nonprofit organization that gives hiring preference to people with significant disabilities. We are an Affirmative Action / Equal Employment Opportunity employer and value workforce diversity. You may apply for any open position online below, download the application and fill it out and bring it in to our office, or come in to our office to fill out an application.

Personal Information

Today's Date
First Name	Last Name	Middle Name
Home Phone	Cell Phone	Email
Best time of day to call: Mornings / Afternoons
Street Address
City	State	ZIP Code
Are you 18 years or older? Yes No
Are you a U.S. Citizen or alien authorized to work in the United States? Yes No
Have you ever been convicted of a felony? Yes No
Please describe your conviction (if applicable):

(Note: You will not be denied employment because of a conviction record, unless the offense impacts the requirements for the job to which you have applied.)

Employment Desired

Position desired (only available positions are shown)

Date you can start

Where did you hear about the position?

Employment History

Please list your last four employers below, starting with your current or most recent employer.

Employer One
Employer Name	Employer Address	Employer Phone
Start Date	End Date	Position
Reason for leaving
May we contact? Yes No
Employer Two (if applicable)
Employer Name:	Employer Address:	Employer Phone:
Start Date:	End Date:	Position:
Reason for leaving:
May we contact? Yes No
Employer Three (if applicable)
Employer Name:	Employer Address:	Employer Phone:
Start Date:	End Date:	Position:
Reason for leaving:
May we contact? Yes No
Employer Four (if applicable)
Employer Name:	Employer Address:	Employer Phone:
Start Date:	End Date:	Position:
Reason for leaving:
May we contact? Yes No

Education

High School
Name and location of high school	Years Attended	Did you graduate? Yes No
Subjects studied
College (if applicable)
Name and location of college:	Years Attended:	Did you graduate? Yes No
Subjects studied:
Trade School (if applicable)
Name and location of trade school:	Years Attended:	Did you graduate? Yes No
Subjects studied:
Other Educational Qualification (if applicable)
Please list any other qualifications or information that is relevant to the job you are seeking:

References

Please list the names of three persons not related to you whom you have known for at least one year.

Reference One
Reference name	Reference address	Reference phone
Business / Relationship to you		Years acquainted
Reference Two
Reference name	Reference address	Reference phone
Business / Relationship to you		Years acquainted
Reference Three
Reference name	Reference address	Reference phone
Business / Relationship to you		Years acquainted

Voluntary Affirmative Action Data

New Leaf is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program. Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as disabled, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program.

We are a company that values diversity. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment. Please complete the information requested below. Thank you for your cooperation.

The following information you provide New Leaf is completely voluntary. Please be aware that we are a not-for-profit, affirmative industry that values diversity and that gives preference in hiring to people with disabilities and veterans. Our set-aside federal contracts through the AbilityOne Program (Javits-Wagner-O’Day Act) require that 75% of all direct labor hours go to people with verifiable disabilities.

Individuals with disabilities is defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).

'Protected Veterans' includes active duty wartime or campaign badge veteran(s), disabled veteran(s), Armed Forces service medal veteran(s), or recently separated veteran(s)

Disabled Veteran means (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.

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 law administered by the Department of Defense.

Recently Separated Veteran means a veteran during the three-year period beginning of the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.

Armed Forces Service Medal Veteran means any 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)

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 05/31/2023

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. We are also required to measure our progress toward having at least 75% of our workforce be individuals with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, 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?
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:

Autism
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
Blind or low vision
Cancer
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or hard of hearing
Depression or anxiety
Diabetes
Epilepsy
Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
Intellectual disability
Missing limbs or partially missing limbs
Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Employee ID (if applicable):

Do you have a disability?

Yes
No

(Be sure to fill out all fields completely.)

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Date of birth:	Gender: Male Female
Do you have a disibility? Yes No	Have you ever been on active duty in the U.S. Armed Forces? Yes No
> Separation date:	Are you the spouse of an active duty US military member? Yes No
Are you a Protected Veteran? (If yes, please indicate your status below) Yes No
Protected veteran status: Disabled Veteran Active duty wartime or campaign badge Veteran Recently Separated Veteran Armed Forces Service Medal Veteran
Ethnic group: 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 or 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 American 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 or 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 Alaska 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 maintain tribal affiliation or community attachment Two or more races - (Not HIspanic or Latino) - All persons who identiify with more than one of the above five races