Affirmative Action Survey

First Name *

Middle Name

Last Name *

Position(s) for which you are applying for

As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report the results to government agencies. Please help us gather this information by identifying your sex, race or ethnicity, or disability status on this form.

Providing this information is completely voluntary. If you choose not to provide some or all of this information, you will not be subject to any negative or adverse treatment.

The information you provide will be used only to monitor our compliance with equal opportunity laws and regulations and for no other purpose. * When we receive this form, we will immediately place it in a confidential file separate from your application. If you wish, you may mail this form to us in an envelope separate from the one that contains your application.

Race/Ethnicity - Select one or moreAmerican 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.Asian: A person having origins in any of the original peoples of the Far Eat, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.Black or African American: A person having origins in any of the black racial groups of Africa.Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish cultures or origin, regardless of race.Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.White: A person having origins in any of the original peoples from Europe, the Middle East, or North Africa.

Disability - Are you a person with a disability?YesNo

Sex - Select OneFemaleMale