Affirmative Action Voluntary Information Form. Ver. 2001
We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.
To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.

In an effort to comply with requirements regarding government recordkeeping, reporting, and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.
Date:
Position(s) applied for:
Referral Source

Walk-In
Government Employment Agency
Private Employment Agency
Employee
Relative
School
Other   

Name of Referral (if applicable):
Applicant Information

Name (last, first, middle)
Phone #
Street Address  
City         State         Zip Code
Please check one of the following Equal Employment Opportunity Identification Groups:
White (not of Hispanic origin)
Black (not of Hispanic origin)
Hispanic
American Indian/Alaskan Native
Asian/Pacific Islander
Other
Sex: Male       Female
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