Applicant Data Survey Form

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, sex, national origin, age, marital or veteran status, medical condition or disability, creed, religion, sexual orientation, access to public assistance and any other legally protected class.

As employers/government contractors, we comply with government regulations and affirmative action responsibilities.

Solely to help us comply with government record keeping, reporting, and other legal requirements, please Fill out the Applicant Data Survey Information. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

Date:

Position Applied for:

Dept.

Last Name:

First Name:

Middle Name:

Telephone:

Address:

City:

State:

Zip Code:

AFFIRMATIVE ACTION SURVEY

Government agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicants. This data is for analysis and affirmative action only.
Submission of information is voluntary.

Check one:

Female

Male

Check one of the following Race/Ethnic Groups:

Caucasian

Asian/Pacific Islander

Hispanic

African/American

American Indian/Alaskan Native

Check if any of the following are applicable:

Vietnam Era Veteran

Disabled Veteran

Other Disability