Please correct the field(s) marked in red below:

APPLICANT DATA RECORD


Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

The Americans with Disabilities Act (ADA) cover individuals that "have a mental or physical impairment that substantially limits one or more major life activities, have a record of such impairment, or who are regarded as having such impairment".

As employers/governmental contractors, we comply with government regulations, including affirmative action responsibilities where they apply.

Solely to help us comply with government recordkeeping, reporting and other legal requirements, we request that you please fill out the Applicant Data Record.  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.  YOUR COOPERATION IS VOLUNTARY.


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Position Applied For:
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Last Name:
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First Name:
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Middle Initial:
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Address:
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City:
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State:
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Zip Code:

VOLUNTARY SURVEY

Government agencies at times require periodic reports on the sex, ethnicity, handicapped, veteran and other protected status of applicants.  This data is for analysis and possible affirmative action only.  SUBMISSION OF INFORMATION IS VOLUNTARY.

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Gender:
Gender:
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Ethnic Origin:
Ethnic Origin:
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Vietnam Era Veteran:
Vietnam Era Veteran:
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Disabled Veteran:
Disabled Veteran:
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Handicapped Individual:
Handicapped Individual:
  1. To receive a copy of your submission, please fill out your email address below and submit.