EQUAL EMPLOYMENT OPPORTUNITY (EEO)
Pollywog Place is subject to certain governmental recordkeeping and reporting requirements for the administration of civil
rights laws and regulations. To comply with these laws, Pollywog Place invites employees to voluntarily self-identify their
race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse
treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of
applicable laws, executive orders, and regulations, including those that require the information to be summarized and
reported to the federal government for civil rights enforcement. When reported, data will not identify any specific
This form will be kept in a confidential file separate from your employment file.
Name (Last, First, MI): _______________________________________________________
Street Address: _____________________________________________________________
City, State, Zip Code: _________________________________________________________
Gender Identification (check one)
Race/Ethnic Identification (check one):
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin regardless of race.
If you did not check “Hispanic or Latino” above, please select one of the following race/ethnic identifications.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial
groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original
peoples of North and South America (including Central America), and who maintain tribal affiliation or
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five
_____ Decline self-identification
Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation,
veteran status, disability, or other protected characteristic.