The Town of Woodstock, Virginia is an equal opportunity employer and values diversity. We are requesting
that you provide us with the information indicated below. This information is kept for statistical reporting
only and is treated in a highly confidential manner. It will not be used by or shared with the selection
committee, and it will be maintained separately from your application file. Your cooperation by providing
this information on a strictly
basis is greatly appreciated. Refusal to provide this information will
have no bearing on your application and will not subject you to any adverse treatment.
Date: _______________________ Name: ___________________________________________
Position applying for: ____________________________________________________________
Gender: Male Female
Ethnicity (check only one):
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 Africa.
Black or African American (not Hispanic or Latino) A person having origins in any of the black
racial groups of Africa.
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 maintain tribal
affiliation or community attachment.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any
of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
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, Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the
above five races.
Equal Employment Opportunity Survey, continued
Disability Status:
Individual with Disabilities**
Not Disabled
** Defined as a person who (1) has a physical or mental impairment which substantially limits one or
more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as
having such impairment(s). For purposes of this definition, an individual with disability(s) is
substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in
employment because of the disability(s).
Veteran Status:
Vietnam Era Veteran Defined as a veteran who (a) served on active duty in the Republic of
Vietnam between February 28, 1961 and May 7, 1975, or (b) served on active duty for a period of
more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was
discharged or released therefrom with other than a dishonorable discharge, or (c) was discharged or
released from active duty for a service-connected disability if any part of his or her active duty was
performed between August 5, 1964 and May 7, 1975.
Special Disabled Veteran Defined as a veteran who is entitled to disability compensation (or who
but for the receipt of military retired pay would be entitled to compensation) under laws administered
by the Veterans Administration for a disability (i) rated at 30% or more, or (ii) rated at 10% or 20%
in the case of a veteran who has been determined under Section 1506 to have a serious employment
disability, or a person who was discharged from active duty because of a service-connected disability.
Other Eligible Veteran Defined as any veteran who served in a “war” declared by Congress, in a
campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary
medal has been awarded.
Not a Veteran
How did you learn about this position?
Town website
Other website _______________________________
Other _________________________________