Equal Opportunity Employment Self-Identify Data Form
The City of Brockton is an Equal Opportunity Employer with a commitment to recruitment and retention of a
diverse and inclusive community. Collection of the following information on gender, race/ethnicity, disability
and veteran status is in compliance with Federal laws and regulations, executive orders and applicable State
laws and regulations.
Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire
or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s
terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin.
The information that you submit will remain confidential and be used by the City only for statistical and
required reporting purposes. Completion of this form is voluntary; failure to provide this information will not
adversely affect your employment and/or employment consideration.
Full Name: Date of Hire:
Department: Position Title:
Gender: Male Female I choose not to ID
ETHNICITY: Are you of Hispanic or Latino Origin? Yes No
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race.)
RACE: Select one or more that apply:
American Indian or Alaskan Native
(Not Hispanic or Latino)
A person having origins in any of the original peoples of North
and South America (including Central America) and who
maintains tribal affiliation or community attachment.
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent
including, for example, Bangladesh, Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Sri
Lanka, Thailand, and Vietnam.
Black or African American
(Not Hispanic or Latino)
A person having origins in any of the black racial groups of
Africa.
Native Hawaiian or Other Pacific
Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
White or Caucasian
(Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe,
the Middle East, or North Africa.
I choose not to ID
Invitation to Voluntarily Self-Identify Veteran Status
We ask that you please consider completing this Invitation to Voluntarily Self-Identify Veteran Status to
help us fulfill our commitments to equal opportunity and affirmative action and to meet our obligations as a
government contractor under the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended
by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA).
“Protected veteran” categories are identified in VEVRAA. This statute requires Government contractors to
take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated
veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal
veterans. VEVRAA defines these classifications as follows:
Protected Veteran classifications are defined as follows:
A "disabled veteran" is one of the following:
a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or
who but for the receipt of military retired pay would be entitled to compensation) under laws
administered by the Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected
disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of
such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the
U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a
campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed Forces service medal veteran" means a veteran who, while serving on active duty in the U.S.
military, ground, naval or air service, participated in a United States military operation for which an
Armed Forces service medal was awarded pursuant to Executive Order 12985.
Self-Identification:
Are you a protected veteran:
I am a protected veteran I am NOT a protected veteran I choose not to ID
How did you learn about the job for which you are applying? (Please limit your selection to
ONE)
1. Walk-In
3. Job Board __________________________
5. Other (Please indicate) _________________
2. City Employee
4. City of Brockton Website
_______________________________________ _________________
Signature Date
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