REQUIRED
Name: _______________________________________________ Date: _________________________
Position applying for: _____________________________________________
OPTIONAL
What is your gender? Male Female I choose not to disclose
What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you
primarily identify.
Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American,
or other
Spanish culture or origin, regardless of race.
White: a person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
Black or African American: a person having origins in any of the black racial groups of Africa.
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.
Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples
of
Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian or Alaska Native: 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.
I choose not to disclose
Veterans and Persons with Disabilities
Section 402 of the Vietnam Era Veterans Readjustment Act of 1974 requires affirmative action to employ and advance in
employment qualified veterans and veterans with a disability of the Vietnam Era. Section 504 of the Rehabilitation Act of
1973, as amended, requires affirmative action to employ and advance in employment qualified individuals with
disabilities.
If you are a veteran and/or have a physical or mental disability, you are invited to volunteer this information. The purpose
is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job
in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not
jeopardize or adversely affect any consideration you may receive for employment.
Disability Veteran with disability Vietnam era veteran I choose not to disclose
The Equal Employment Opportunity Commission (EEOC) allows organizations to invite applicants to self-identify
gender and race. Completion of this data is voluntary and will not affect your opportunity for employment, or
terms or conditions of employment. Administrative information is required.
HR 3/16
