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voluntary affirmative action info

Voluntary Affirmative Action Information

Completion of the information below is voluntary.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any other legally protected status.

Today's Date:

09-05-08

Position(s) applied for:

Referral Source:

Employee

Relative

Walk-in

School

Government Employment Agency

Private Employment Agency

Other, please specify:

Applicant Information:

First Name:

Middle Name:

Last Name:

Address:

City:

State, Zip:

Phone:

Email:

As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that your survey is not part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

Select gender:

Select Race/Ethnicity:

SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISBALED VETERANS AND INDIVIDUALS WITH PHYSICAL OR MENTAL HANDICAPS OR DISABILITIES:

Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disbaled veterans and veterans of the Vietnam Era, and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accomodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.

IF YOU SO WISH TO BE IDENTIFIED, PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE:

	Vietnam Era Veteran
	Disabled Veteran
	Individual with a Disability

—To be completed by applicant—
—Not for interview purposes—
—To be filed separately from application—

This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulation.