Last, First, Middle
CONNECTICUT STATE COLLEGES &
EMPLOYMENT APPLICATION – VOLUNTARY SUPPLEMENT
In order to meet State and Federal reporting requirements, we are requesting that you voluntarily supply the following
information. This data will not be considered in the evaluation of application.
A. GENDER: _______________Female _______________Male
B. RACE/ETHNIC DATA:
1. _________AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origins in any of the
origins in any of the original peoples of North America, and who maintain cultural identification
through tribal affiliation or community recognition.
2. _________ASIAN/PACIFIC ISLANDER: Persons having origins in any of the original peoples of the
Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for
example: China, Japan, Korea, the Philippine Islands, and Samoa.
3. _________BLACK/AFRICAN-AMERICAN (NOT OF HISPANIC ORIGIN): Persons having
origins in any of the black racial groups of Africa.
4. _________HISPANIC: Persons of Mexican, Puerto Rican, Central or South American or other Spanish
culture or origin, regardless of race.
5. _________WHITE (NOT OF HISPANIC ORIGIN): Persons having origins in any of the original
peoples of Europe, North Africa, or the Middle East.
C. PRIMARY SOURCE OF JOB INFORMATION:
Where did you learn about the job/position? Check and complete below.
_________Connecticut State Colleges & Universities (CSCU) Website
tment of Administrative Services (DAS) Website
3. _________Other Website _____________________________________________________________
4. _________Newspaper, Professional Journal, Radio or TV Advertisement
Please give the name of the publication/station, etc.:_________________________________
5. _________Paper Posting
6. _________Direct e-mail or paper mailing
7. _________Career Fair: Event/location:__________________________________________________
8. _________Other. Please Specify:_______________________________________________________
CSCU is committed to a policy of equal opportunity/affirmative action for all qualified persons. CSCU does not
discriminate in any employment practice, education program, or educational activity on the basis of race, color, religious
creed, sex, age, national origin, ancestry, marital status, sexual orientation, gender identity or expression, disability
(including, but not limited to, intellectual disability, past or present history of mental disability, physical disability, or
learning disability), genetic information, retaliation, veteran status or any other basis prohibited by Connecticut state
and/or federal nondiscrimination laws. CSCU does not unlawfully discriminate in employment and licensing against
qualified persons with a prior criminal conviction.
Inquiries regarding the CSCU’s nondiscrimination policies should be directed Leah Glende, Manager of Diversity and
Inclusion, State of Connecticut, CSCU, 61 Woodland Street, Hartford, CT 06105, (860) 723-0727 or email@example.com.
AN AFFIRMATIVE ACTION/EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER