Applicant Information
Invitation to Identify for Affirmative Action Purposes
Our organization is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, or any other basis prohibited by federal, state, or local law. No question on this form is intended to secure information to be used for such discrimination. Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with Equal Opportunity principles.

Name:
Position Applied For:

(Please select one)
Female	Male

(Please select one)
Hispanic/Latino	Not Hispanic/Latino (If not Hispanic/Latino please address race below)

INDICATE THE APPROPRIATE RACE GROUP(S) (Response not required if identified as Hispanic/Latino above):
White		Black/African American		Asian
Native Hawaiian or other Pacific Islander		American Indian/Alaskan Native

How did you hear about this position?
Advertisement			School/College
Employee Referral			State Job Service
Employment Agency			Temporary Agency
Government Agency			Walk In
Recruiter			Other