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The following conditions will be required for some job assignments.
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Occupational Skills Learned or Special Training Received; Academic and Professional Achievements or Activities.
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What is your current active Security Clearance?
Have you ever been denied a Security Clearance or had one revoked or suspended?
Have you ever been Convicted of a crime, other that Minor Traffic Violations, in the last 15 years?
Have you ever been a member of U.S. Armed Services?
If you are a current or former Government employee, you may be subject to one or more of the various Federal regulations and restrictions pertaining to employment in the private sector.
Please take this time to complete all of the following. This will help us in expediting your application for employment. Should you have any questions, do not hesitate to contact the Human Resources Department.
Civilian:
Military:
During your Government service, have you ever performed procurement functions (negotiation, award, administration, or approval of a contract or a change in a contract; selection of a contractor; management of a procurement program; quality assurance, operational or developmental testing; approval of payment or auditing under a contract)?
During your Government service, have you ever performed duties, which involved direct or indirect contact with any representative at S3, Inc.?
Certain Federal regulations, if applicable, may require that you inform your agency of any contact regarding prospective employment with S3. Consideration for employment by S3 may require that you seek advice from the appropriate Designated Agency Ethics Official regarding the applicability of Federal regulations to that employment. Provisions of this information are strictly voluntary and refusal to provide it will not subject you to any adverse treatment. Any information provided will be kept confidential and used only in accordance with the pertinent federal and state regulations.
Are you able to perform the essential functions of this job with or without reasonable accommodations?
List Agreements/Restrictions with Prior/Present Employers which impose constraints on your professional activities (pre/post employment) including trade secrets, patent agreements, proprietary information, non-compete agreements, OCIs, transition leave, etc. Legal Documentation must be provided prior to employment.
Do you have any ownership interest in a non-publicly traded company or a working relationship with any company that would demonstrate a potential conflict of interest? If Yes, please explain.
Cover LetterYou can use the text area for a cover letter and any supplementary information you would like to provide about your career goals, availability, best times to contact you, etc.
I certify that all information given by me on this application for employment, or in supplemental form, is true and correct to the best of my knowledge. I understand that false or misleading statements or consequential omissions of any kind are sufficient cause for dismissal. I understand that I may be terminated if my job requires a security clearance, and I am unable to obtain and retain a security clearance, and no other positions are available for which I am qualified and selected.
I understand that I may be terminated if my job requires a security clearance, and I am unable to obtain and retain a security clearance, and no other positions are available for which I am qualified and selected.
In addition, I understand that I must provide documents verifying my identity and legal right to work in the United States (as required by the Immigration Reform and Control Act of 1966), as well as degrees, transcripts, and professional certifications, as conditions of my employment. I further understand that employment by S3 is not for a fixed term unless it is stated in writing and signed by an Officer of the company. I also understand that if I am employed (or later transferred) by S3 for assignment to a contract being performed for certain Federal agencies that I may be required to sign a consent form allowing S3 to conduct personal drug testing, and that I may be required to sign a procurement integrity certificate, and the my refusal to sign either form may subject me to disciplinary action up to and including termination.
I also understand that if I am employed (or later transferred) by S3 for assignment to a contract being performed for certain Federal agencies that I may be required to sign a consent form allowing S3 to conduct personal drug testing, and that I may be required to sign a procurement integrity certificate, and the my refusal to sign either form may subject me to disciplinary action up to and including termination.
For and in consideration of S3 placing me in active candidacy for employment, I authorize S3 to verify the information provided in this application or in supplemental form, and to request from my reference, my previous employers, schools, including colleges and universities attended, law enforcement agencies, or other sources, information concerning my work habits, on-the-job performance, general character, and matters of record including, but not limited to, academic history, degrees earned, and grade point average. I also authorize the release of this information to S3 and release any organizations or individuals who reply to inquiries permitted hereunder from liability in the event such investigation results in a decision not to employ me. I understand this information will be used for official purposes, and will be treated by S3 as confidential at all times.
S3 is an Equal Opportunity Employer and subscribes fully to the principles of Equal employment Opportunity. S3 ensures that all qualified applicants are considered for hire, promotion, and job status, without regard to race, color, religion, gender, national origin, age, disability, status as a disabled veteran or veteran of the Vietnam era, or any other basis prohibited by law.
S3, Inc. is an Equal Opportunity, Affirmative Action Employer. It is the policy of S3 to recruit, hire, train and promote qualified persons in all job classifications without regard to race, color, religion, gender, disability, national origin, marital status, veteran status or age, except where a bona fide occupational qualification exists. You need not provide information in order to be considered for employment by S3, however, the information you provide below will be used by S3 to help fulfill its reporting requirements to federal and state agencies and will be kept in a confidential file separate from your application for employment.
7. Affirmative Action Survey
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
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 disable at any time, we are required to ask all of our employees to update 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.
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 life activity, or if you have a history or record of such an impairment of medical condition.
Disabilities include, but are not limited to:
- Blindness
- Deafness
- Cancer
- Diabetes
- Epilepsy
- Autism
- Cerebral palsy
- HIV/AIDS
- 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)
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.
* 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 U.S. 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.
Check All That Are Applicable
Referral Source for this application:
This form is to be completed by all prospective employees/consultants. Please enter all requested information.
Instructions and Preliminary Questions
Various federal laws and regulations restrict the post-government employment activities of former government officers and employees and place conditions upon current government employees who engage in discussion regarding post-government employment. These laws and regulations are designed to protect you and S3. This document helps S3 determine which restrictions, if any, apply to you and enables the company to assess their impact upon employment discussion, hiring decisions and future work assignment at S3 *1.
1. As a preliminary matter, please check which of these four mutually exclusive situations apply to you. Then complete only the section(s) required.
| a. I am currently employed by the U.S. Government. | Complete Sections A, B, C & D |
| b. I am a former U.S. Government officer or employeewho left government service within the past year. | Complete Sections B, C & D |
| c. I am a former U.S. Government officer or employeewho left government service more than one year ago. | Complete Section C & D |
| d. I have never been employed by the U.S. Government. | Complete Section D Only |
Reporting and Recusal for Current Government Employees
If you are a current government officer or employee, you hereby agree to report to your supervisor or your Designated Agency Ethics Official (DAEO) any contacts between S3 and you regarding employment, and by signing this form you hereby certify and represent that you have done so, if:
Your current duties in the U.S. Government include participation (i.e. making decisions or recommendations, approving or disapproving, rendering advice, investigating, and the like) in any procurement or other matter involving S3. If you perform such duties, you agree to notify your supervisor and DAEO promptly of your employment/consultant interests with S3. You further agree that during the period of discussing employment or consultant services with S3, you will recuse yourself from participating in any procurement or other matter involving S3 in accordance with applicable federal laws or regulations, unless an appropriate government authority waives your disqualification pursuant to such laws or regulations. Any questions regarding the nature or extent of your obligations in this regard should be raised directly with your DAEO.
OR
Your current duties in the U.S. Government DO NOT include participation (i.e. making decisions or recommendations, approving or disapproving, rendering advice, investigating, and the like) in any procurement or other matter involving S3; but if, during the period of discussing employment or a consultant relationship with S3, your duties with the government change so as to require participation in any procurement or other matter involving S3, you agree to notify your supervisor and DAEO promptly of your employment/consultant interests with S3. You further agree to recuse yourself from such participation in accordance with applicable federal laws or regulations, unless an appropriate government authority waives your disqualification pursuant to such laws or regulations. Any questions regarding the nature or extent of your obligations in this regard should be raised directly with your DAEO.
Military Transition Leave
You may be hired while on military transition leave from the military, subject to the following conditions and restrictions: 1) You have obtained prior written approval from your command for 'outside employment' with S3; and 2) If you are a commissioned military officer, you may not represent, communicate or appear on behalf of S3, or otherwise act as an agent for S3, before any government agency or official with respect to any matter, regardless of prior involvement therein, until after your final separation date. Condition 2) does not apply to military enlisted personnel or non-commissioned officers.
2. a. Are you currently or do you expect to be on transition leave from the U.S. military?
b. If yes, please state the actual or expected start and end dates of your terminal leave period:
The following information and questions apply to all applicants who are currently or were at any time within the past twelve months employed by the U.S. Government.
A current U.S. Government officer or employee, or a former U.S Government officer or employee who left the government within the last twelve months, may not accept compensation from S3 as an employee, officer, director or consultant within a period of one year after serving in any of the roles identified below, in connection with a procurement in which S3 was selected for award of and/or awarded a contract that exceeded $10 million.
Please answer Yes Or No to the following questions.
3. Within the last twelve months, have you served in any of the following capacities in connection with a procurement in which S3 was selected for an award or awarded a U.S. Government contract (including grants, cooperative agreements, Cooperative Research and Development Agreements (CRADAs) or Broad Agency Announcements (BAAs)) that exceeded $10 million (including options):
4. Within the last twelve months, have you served in a any of the following capacities in connection with a U.S. Government contract awarded to S3 (including grants, cooperative agreements, Cooperative Research and Development Agreements (CRADAs) or Broad Agency Announcements (BAAs)) that exceeded $10 million (including options):
5. Within the last twelve months, have you personally made any decisions for the U.S. Government agency that employed you involving:
Award of a contract, subcontract, modification, task order or delivery order in excess of $10M to S3?
Establishment of overhead or other rates applicable to S3 contract(s) valued in excess of $10 million?
Approval of contract payment(s) in excess of $10 million to S3?
Payment or settlement of a claim in excess of $10 million to S3?
The following information and questions apply to all applicants (except military enlisted personnel and non-commissioned officers) who are currently or were at any time formerly employed by the U.S. Government.
If you seek employment or consultant status with S3, or you are later tasked by S3 to work on the same, particular matter3 in which you were personally and substantially involved4 while in government service, or which was actually pending under your official responsibility5 during your last year of government service, federal law either forever prohibits or restricts for two years your ability to represent or communicate or appear on behalf of S3 before the U.S. Government, with the intent or effect of influencing the government in any way with respect to that same, particular matter. These restrictions apply to all current and former U.S. Government employees, including commissioned officers, but do not apply to military enlisted personnel or military non-commissioned officers. These restrictions
do notapply to any matters other than those described herein. Please note however that if you are hired by S3 and are subsequently assigned to work on any particular matter described above, you may not do so unless and until you contact S3’s President and CEO or designated legal counsel for a determination on what restrictions may apply to such tasking.
6. To assist in determining if your planned work at S3 will comply with these requirements, please answer the following questions:
a. Are you seeking employment or consultant status with S3 to work on the same, particular matter (as defined and explained at endnote 3) in which you were personally and substantially involved (as defined and explained at endnote 4), or which was actually pending under your official responsibility (as defined and explained at endnote 5), while you served in the government?
b. If yes, please use the space below to provide a detailed description of the matter, the nature of your duties in government service, the time during which you performed such duties and the expected nature of your duties at S3.
Federal law generally prohibits “senior government employees” from communication or appearing before their former agency seeking action from that agency on any matter, regardless of their involvement in that matter, for a period of one year. Senior government employees are defined as persons paid on the Executive Schedule; persons whose rate of basic pay is equal to or greater than 86.5% of the rate payable for Level II of the Executive Schedule; persons who on November 23, 2003, were paid a rate of basic pay equal to or greater than the rate of basic pay for Level 5 of the Senior Executive Service (i.e., $134,000); active duty commissioned officers whose pay grade is 0-7 or above; and Presidential and Vice Presidential appointees to certain White House positions.
7. If you are currently a senior government employee as defined above or you were within the last year a senior government employee, please indicate on the line below your pay grade or rank and the actual or expected date of retirement or final separation from the government.
I hereby certify that the answers given by me in this Questionnaire and Certification are true, accurate and complete to the best of my knowledge and belief. If I subsequently learn than any response contained herein is incorrect, inaccurate or incomplete, I agree to notify S3 promptly. In addition, I hereby certify and agree that I will abide by, comply with and observe all obligations, agreements, directive, restrictions and prohibitions set forth herein, including, without limitation, any obligation to report any contacts or employment discussions with S3 to the appropriate government personnel and to undertake any required recusals or disqualifications from matters involving S3.
Endnotes:
1. 'S3' for purposes of this Questionnaire and Certification refers to S3 and all of its subsidiaries and affiliates.
2. 'United States Government' or 'government' for the purposes of this Questionnaire and Certification refers to any civilian agency, administration or division, as well as branch, department or command of the military. Military Reservists and National Guard personnel not recalled to active duty, mobilized, or otherwise not performing any extended periods of active duty beyond their normal annual two-week commitment, are not considered government officers or employees.
3. A 'particular matter' means a contract, procurement, claim, dispute, application, request for a ruling or other determination, judicial or other proceeding, controversy, investigation, charge, accusation, arrest or other particular matter involving a specific party or parties in which the United States is a party or has a direct and substantial interest. Thus, a particular matter is some definable and isolatable transaction in which the government has a direct and substantial interest and which involves any specific non-governmental party. Determine whether particular matters are the same involves a consideration of all relevant factors, and generally requires that the same subject matter and the same nucleus of operative facts be present in both matters.
Please also note what is not a particular matter.General areas of activity or matters internal to the government (and thus, do not involve the government or a specific party or parties), such as developing policies, engaging in general rule-making or formulating technical, administrative or programmatic concepts or policies are not particular matters.
4. 'Participating personally and substantially' means being actively and significantly involved in a matter. 'Participating personally' means participating directly and includes the direct and active supervision of a subordinate's participation in the matter. 'Participating substantially' means that the involvement is of significance to the matter. Substantial participation requires more than official responsibility, knowledge, perfunctory involvement, or involvement of an administrative or peripheral issue. Participation may be substantial even though it does not determine the outcome of a particular matter. A finding of substantiality should be based not on the effort devoted to the matter, but on the importance of the effort. While a series of peripheral involvement may be insubstantial, the single active of approving or participating in a critical step may be substantial.
5. 'Official responsibility' means the direct administrative or operating authority, whether intermediate or final, and exercisable alone or with others, and personally or through subordinates, to approve, disapprove or otherwise direct government action. Note than an employee’s recusal from or other non-participation in a matter does not remove it from their official responsibility. A matter is 'actually pending' under an employee’s official responsibility if the matter was referred to or under consideration by persons within the employee's area of responsibility. However, this restriction will not apply unless the former employee knows or reasonably should know that the matter had been under their official responsibility during their last year of government service.
