VOLUNTARY SELF-IDENTIFICATION FORM

EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION EMPLOYER

TO ALL APPLICANTS:

This company is an Equal Opportunity and Affirmative Action Employer. We request your cooperation in providing the following information that will be used in accordance with statutes and regulations regarding Equal Employment and Affirmative Action. Providing this information is voluntary. All information received will be kept confidential. It will remain separate from your employment application and will not be used in any way during the interviewing or hiring process.

Name______________________________________________________________

Last First MI

Today’s Date_______________________ Center Name______________________

Position Applied ____________________________ Job#____________________

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GENDER:

____________ Male ____________ Female

White (not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East

Black (not of Hispanic origin): 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 or origin, regardless of race.

Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Pacific Islands, or Indian Subcontinent. This area includes, for example: China, India, Japan, Korea, the Philippine Islands, Samoa.

American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

RACE/ETHNIC CATEGORY: (Check One)

____________ White (not of Hispanic origin)

____________ Black (not of Hispanic origin)

____________ Hispanic

____________ Asian or Pacific Islander

____________ American Indian or Alaskan Native

____________ Bi or Multi-racial

REFERRAL SOURCE:

____________ Private employment agency ____________ Walk-in

____________ Newspaper (specify) ____________ Employee referral

____________ Educational Institution ____________ Other:

____________ State or Community Agency: Name: ______________________________