All applicants are treated equally without regard to race, color, religion, sex,
national origin, age, marital or veteran status, medical condition or handicap,
or any other legally protected status.
As an employer with an Affirmative Action Program, we comply with government
regulations, including Affirmative Action responsibilities where they apply.
The purpose for this Data Record is to comply with government record keeping,
reporting, and other legal requirements. Periodic reports are made to the government on the
following information. The completion of this Data Record is optional. If you choose to
volunteer the requested information please note that all Data Records are kept
in a Confidential File and are not a part of your Application for Employment or
personnel file. YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT
AFFECT ANY EMPLOYMENT DECISION.
Date:
Position Desired:
Referral Source
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Employee
Employment Agency
Self
Union
School
Other
Name of Source if Applicable:
Applicant's Name:
Last:
First:
Middle:
Telephone:
(
)
Address
Street:
City:
State:
Zip:
Check One:
Male:
Female:
Black:
All persons having origins in any of the
Black racial groups of Africa.
Hispanic:
All persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture, regardless of race.
Asian:
All 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.
Native American:
All persons having origins in any of the original peoples of
North America, and who maintain cultural identification through
tribal affiliation or community recognition. (Meets Bureau of
Indian Affairs definition standards).
White:
(Or Not Covered Above)
To be completed by applicant. Not for interview
purposes. To be filed separately from application.
