ADDITIONAL INFORMATION – VOLUNTARY SELF-IDENTIFICATION FORM FOR APPLICANTS
The Company is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order
to comply with these laws, the employer invites applicants to voluntarily self-identify their race or ethnicity along with protected Veteran status. Submission
of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept conﬁdential and
may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be
summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any speciﬁc individual.
Name: __________________________________________________________ Telephone No.: __________________________ Gender: ____________
(Last / First / Middle)
(Address / City / State / Zip)
ETHNIC BACKGROUND: (Check One)
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.
q Native Hawaiian or Other Paciﬁc Islanders (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other
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 Alaskan 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 identify with more than one of the above ﬁve races.
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:
• Disabled Veteran: 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 a person who was discharged or released from
active duty because of a service-connected disability.
• Recently separated Veteran: Any Veteran during the three-year period beginning on the date of such Veteran’s discharge or release of active duty in the
U.S. military, ground, naval, or air service.
• Active duty wartime or campaign badge Veteran: 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.
• Armed Forces service medal Veteran: 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.
Veteran Status: If you believe you belong to any of the categories of protected Veterans listed above, please indicate by checking the appropriate box below.
As a government contractor subject to VEVRAA, we request this information to measure the effectiveness or the outreach and positive recruitment efforts
we undertake pursuant to VEVRAA.
q I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
q I AM NOT A PROTECTED VETERAN
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.
HOW WERE YOU REFERRED TO US:
Newspaper Ad q Private Placement Firm q State Employment/Workforce Agency
School Placement Ofﬁce q Company Web Site/jobs.mdu.com q Employee Referral________________________________
OTHER: q Name of Referral Source: ____________________________________ q Veteran Referral Source: ________________________________
q Disabled Individual Referral Source: ___________________________ q Female Referral Source: ________________________________
q Minority Referral Source: ____________________________________
Date of Application: ___________________________________ Job Applying For: _______________________________________________________
Signature of Applicant: (q Applicant digitally signed this document): ___________________________________________________________________
An Equal Opportunity Employer/Afﬁrmative Action employer. All qualiﬁed applicants will receive consideration for employment without regard to race,
color, religion, gender, sexual orientation, gender identity, national origin, disability, or protected Veteran status.
– Conﬁdential Information - Return to Human Resources Dept. –
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