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
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.
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?
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
Islander (Not Hispanic or Latino)
I do not wish to disclose.
Asian (Not Hispanic or Latino)


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