Applicant Data Record
We are an Equal Opportunity Employer and do not discriminate on the basis of religion, sex, age, national origin, political affiliation,
mental or physical disability, race, color, or status as a disabled veteran and promote full realization of equal employment opportunity.
Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data
Record. We appreciate your cooperation. Completion of this survey is strictly voluntary and will not subject you to adverse treatment.
This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.
(PLEASE PRINT)
Date:
Position applied for:
Referral source:
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Friend
Relative
Walk-in
Employment agency
Other
The following data is for analysis and affirmative action only. Submission of information about a disability is voluntary.
Gender:
Male
Female
Choose Not to Disclose
Race/Ethnic Group - Check one:
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin
regardless of race.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand, and Vietnam
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and
South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.
Race missing or unknown – Applies to Applicants only, where a resume or application that is screened is received without any
racial or ethnic identification and no further contact is made with the applicant.
Choose Not to Disclose
Veteran Status - Check one:
Not applicable
Vietnam Era Veteran
Armed Forces Service Medal Veteran
Recently Separated Veteran (within the last three years)
Other Protected Veteran
Choose Not to Disclose
