11.
F = Female
B - Asian or Pacific Islander
C - Black, Not of Hispanic Origin
E - White, Not of
Hispanic Origin
9.
place the RACE/ETHNIC Code which indicates the group with which you identify yourself.
appropriate box in block 11, to show your sex.
10.
A - American Indian or Alaskan Native D - Hispanic
( ) 13 - ARNG unit
( ) 14 - ANG unit
( ) 15 - AZNG HRO Web Site
( ) 05 - Friend or Relative Not Working for Agency
( ) 06 - Telephoned the Technician Personnel Office
( ) 07 - Walked into the Technician Personnel Office
( ) 08 - Federal, State, or Local Job Information Center ( ) 16 - Other ~ Specify
( ) 03 - Veterans Administration ( ) 11 - National Guard EEO Office
( ) 04 - Friend or Relative Working for Agency ( ) 12 - Private Employment Office
( ) 01 - Bulletin Board or Announcement ( ) 09 - ARNG Recruiting Office
( ) 02 - Office of Personnel Management ( ) 10 - ANG Recruiting Office
ARIZONA NATIONAL GUARD
APPLICANT BACKGROUND SURVEY
For use of this form, see AZ ARNG 690-335-1/AZ ANGR 40-335-1; the proponent agency is HRO
GENERAL INSTRUCTIONS:
application and given to the Equal Employment Manager for inclusion in the statistics compiled for the
Affirmative Action Plan.
pencil or pen.
in each box.
PRIVACY ACT INFORMATION
General:
December 31, 1974, for individuals completing Federal records and forms that solicit personal information.
Authority:
Purpose and Routine Uses:
opportunity recruitment program to help insure that agency personnel practices meet the requirements of Federal
law.
Effects of Nondisclosure:
based on this information.
Information Regarding Disclosure of your Social Security Number Under Public Law 93-579, Section 7 (b):
Solicitation of the Social Security Number (SSN) is authorized under provisions of Executive Order 9397 dated
November 22, 1943.
1. 2.
3. 4.
8. hoose
up to three choices).
5. 6. 7.
1 = YES
M = Male SEX:
In the box in block 10, Please categorize yourself in terms of race and sex using the definitions below.
Check the
RACE/ETHNIC CODE
Upon submission, this survey is detached from the Your responses are voluntary.
Please print entries in Please answer each of the questions to the best of our ability.
Read each item thoroughly before completing the appropriate code number Use only capital letters.
This information is provided pursuant to Public Law 935-579 (Privacy Act of 1974)
Sections 1302, 3301, 3304, and 7201 of Title 5 of the U.S. Code
The information form this survey is used for research and for a Federal equal
Address questions concerning this form to the Human Resources Office.
Providing this information is voluntary, no individual personnel selections are made
It is used to relate this form with other records that you file with Federal agencies.
Announcement No.: (Month, Day, Year): Date
Name (Last, First, MI): Title of Position Applying For:
(You may cHow did you learn about the particular position for which you are applying?
Social Security Number Year of Birth Do You Have Any Physical Disability
2 = NO
AZNG Form 335-4-R (1 Apr 92)
