Employment Application

Kairos is an EEO Employer/Veterans/Disabled.

General Information

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions).
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.


List name and location of college or university Major Years Attended Degree or Diploma

Please list additional licenses and credentials.

List other experience, training or skills that qualify you for this position (e.g., bilingual).

Employment History

Please complete if less than five years work history is listed above.

Date Employer Name and Contact Number Position

Work Related Professional References

Please provide the names and phone numbers of at least three work related professional references, such as previous supervisors, co-workers. (No friends or family, please!)

In case of an emergency, please notify:

Please read each statement carefully before signing

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date

I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational history, driving records, and criminal history. I authorize any person, school, current and former employer, and any other organization or agency to provide information relevant to such investigation and I hereby release all persons and corporations requesting or supplying information pursuant to such investigation from all liability or responsibility to me for doing so. I understand that I have the right to make a written request within a reasonable period of time for a complete disclosure of the nature and scope of any investigation.

I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice.

I have read, understand, and by my signature consent to these statements.

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. 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 tear of any punishment because you did not identify as having a disability earlier

How do I know if I 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 1life activity, or if you have a history or record of such an impairment or medical condition

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebralpalsy
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or
    partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
Page 2 of 2

Reasonable Accommodation Notice

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.

1Section 503 of the Rehabilitation Act of 1973,as amended. For more information about this form or the equal employment obligations of Federalcontractors,visit the U.S. Department of abor'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.

Pre-Employment/New Employee
EO 11246 and Vietnam Era Veterans Readjustment Assistance Act (VEVRAA)

Voluntary Survey

Kairos is a government contractor subject to Executive Order 11246 and the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), which requires affirmative action to employ and advance in employment qualified individuals without regard to race, color, national origin, religion, or veteran status.

We are compiling information to assist us in complying with our Affirmative Action Program goals, and are requesting you to complete this survey.

Submission of this information is completely voluntary. Information provided will be kept confidential and used only in ways consistent with Executive Order 11246, VEVRAA and government reporting requirements. Refusal to provide information will not subject you to any adverse employment decision.

Completion of this portion is required regardless of participation in the survey.

Mark One of the Following Categories for Race: (Please mark one in addition to the selection above. If you are more than one race please mark the "Two or More Races" box):

You are a "protected veteran" under VEVRAA if you belong to one of the veterans categories described below:

  • Disabled Veteran
    Veteran who served on active duty in the U.S. military and is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs, or was discharged or released from active duty because of a service-connected disability.

  • Active Duty Wartime or Campaign Badge Veteran
    A veteran who served on active duty in the U.S. military during a war, or in a campaign or expedition for which a campaign badge was authorized under the laws administered by the Department of Defense.

  • Recently Separated Veteran
    A veteran separated during the three-year period beginning on the date of the veteran's discharge or release from active duty in the U.S. military.

  • Armed Forces Service Medal Veteran
    A veteran who, while serving on active duty in the U.S. military, participated in a U.S. military operation that received an Armed Forces service medal.

Application Documents (Optional)

Upload your resume, cover letter, reference letters, or other application documents below. (optional)

*Please ensure that the combined size of your documents does not exceed 8 MB.

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By phone: (541) 956-4943
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