Self Identification Form printable pdf download

Self Identification Form

Applicant Affirmative Action Program

Self Identification Form

Required Information

Name: ______________________________________Date of Application:___________

Position(s) for which you are applying: ______________________________________

Voluntary Information

NEMA is a government contractor and to comply with the regulations for equal employment

opportunity and affirmative action (EEO/AA), we must track our applicants by gender and

race/ethnicity and the position they applied for to the government. We are an organization that

values diversity and encourages women and minorities to apply. For this reason, we invite you to

indicate your gender and race/ethnicity below. This information is kept separate from your

application.

Submission of this information is voluntary and refusal to provide it will not subject you to any

adverse treatment. Responses will remain confidential within the Human Resources Department;

and will be used only for the necessary information to include in our Affirmative Action

Program and reporting requirements to the government. When reported, data will not identify

any specific individuals.

Gender:

Male

Female

Definitions of race/ethnicity are on the next page (as defined by the Equal Employment

Opportunity Commission).

Race/Ethnic Identification (check one):

Are you Hispanic or Latino?

Yes

If you answered “Yes” you have completed this form. If you answered “No” please select a

race from the options below.

White (Not Hispanic or Latino)

American Indian or Alaska Native

Black or African American (Not

(Not Hispanic or Latino)

Hispanic or Latino)

Two or More Races (Not Hispanic or

Native Hawaiian or Other Pacific

Latino)

Islander (Not Hispanic or Latino)

I do not wish to disclose.

Asian (Not Hispanic or Latino)

Self Identification Form