NAME: _________________________________ PHONE : _____________________________ DATE: ________________________________
As an Equal Opportunity Employer, Rocky Mountain College is required to report the composition of its work force to state and federal governments. The information on this form will be
filed separately and will not be used to make a decision about your employment. It will be available only to the person responsible for government reporting or for affirmative action
reasons and safeguards will be used to prevent the discriminatory abuse of this information. Your voluntary cooperation is appreciated.
GENERAL INFORMATION: (Please enter the requested information and/or check the box beside the appropriate designation)
Birth Date: (mm/dd/yr) __________/_________/________ Gender: (Please check the box) Male Female
(Please check the box beside the ethnic group with which you most identify in custom and communication)
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 America.
Black or African American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander:A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian: A person having origins in any of the original peoples of the far East, Southeast Asia, or the
Indian Subcontinent, including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand and Vietnam.
American Indian or Alaska Native: 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: All persons who identify with more than one of the above five races.
(Please check if applicable)
Nonresident Alien A person who is not a citizen or national of the United States and who is in this country on a visa or temporary
basis and does not have the right to remain permanently.
(Please check if applicable)
Vietnam Era (August 5, 1964 – May 7, 1976) Other than Vietnam Status Spouse of deceased veteran
Disabled Vietnam Veteran Disabled veteran (other than Vietnam)
Dates of Service: From: _________ To: ____________
Total Active Service Time: Years: _______ Months:_______ Days: _______
DISABLED STATUS: (Please check yes or no for each area)
YES NO Do you have physical, sensory or medical impairment which substantially limits one or more life activities (e.g. walking, seeing, hearing, breathing, learning)?
YES NO Do you have a physical, mental or other health condition that has lasted for six months or more and which limits the kind of or amount of work you can do at a job?
I prefer not to complete this form.
VOLUNTARY and CONFIDENTIAL EQUAL EMPLOYMENT
OPPORTUNITY (EEO) QUESTIONNAIRE
(This information is for record-keeping and for Federal & State reporting purposes only.)