As an employer, the City of Lebanon is required to collect, record, and compile personnel affirmative action data. This
information is confidential and will be retained in Human Resources separate from your application for employment.
Supplying this information is voluntary; failure to provide this information will not adversely affect consideration for
employment. It is the City’s policy to consider applicants on an equal basis for all positions without regard to sex, age,
race, color, religion, national origin, marital or veteran status, sexual orientation, disability or other protected status or
activities in accordance with law.
Name (please print or type) Birth Date
Position Applying For
Sex: _____ Mal
e U.S. Citizen: Yes
_____ Female No
Check one of the following:
American Indian or Alaskan Native – A person having origins in any of the original peoples of
North America and South America (including Central America), and who maintains tribal affiliation or community
attachment.
Asian – 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.
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 original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
White – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic or Latino (All races) – A person of Mexican, Puerto Rican, Cuban, Central or South American, or other
Spanish culture or origin, regardless of race.
If you checked Hispanic, please check one of the following Ethnic Groups:
Hispanic or Latino (White race only) – A person of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, and of the White race.
Hispanic or Latino (all other races) – A person of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, and of any race other than White.
Have yo
u ever been convicted of a crime? Yes No
If yes, please explain the circumstances including when, where, and the disposition of the case. (Exclude those cases
contained within expunged juvenile record and minor traffic violations.) Conviction does not necessarily disqualify you
from further consideration for employment.
Volunteer Application(R0
117
.doc