Office of the Secretary of State
Department of Personnel
Equal Employment Opportunity (EEO) Request
• For purposes of Equal Employment Opportunity and Affirmative Action, please complete and return the EEO Request form
with your employment application. Mark only one selection for both race and disability.
• Completion or omission of this information is voluntary and will in no way affect employment opportunities with
the Office of the Secretary of State.
• This form will be maintained in a separate file with the Department of Personnel and will not be kept with the graded
employment application.
Name:________________________________________________________ Date: _________________________________________
Social Security Number:_________________________________________________________________________________________
Race Female Male
Caucasian/ A person having origins in any of the original people of Europe,
White: North Africa or the Middle East. Not of Hispanic origin. ❏ A ❏ G
Black/ A person having origins in any of the black racial groups of Africa.
African American: Not of Hispanic origin. ❏ B ❏ H
American Indian A person having origins in any of the original people of North and
or Alaska Native: South America, including Central America, and who maintains tribal
affiliation or community attachment. ❏ C ❏ J
Asian: A person having origins in any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent, including, but not limited to
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand and Vietnam. ❏ D ❏ K
Hispanic/ A person of Mexican, Puerto Rican, Cuban, Central or South
Latino: American, or other Spanish culture or origin, regardless of race. ❏ E ❏ L
Native Hawaiian/ A person having origins in any of the original peoples of Hawaii,
Other Pacific Islands: Guam, Samoa or other Pacific Islands. ❏ O ❏ P
Printed by authority of the State of Illinois. March 2021— 2M — Per D 173.5
Disability
❏ Yes
❏ No
