2013 Affirmative Action Information Form printable pdf download

AFFIRMATIVE ACTION INFORMATION FORM

Sho-Me Power Cooperative (SMP) is an equal opportunity employer. It is SMP’s policy to provide equal opportunity to all

qualified persons, regardless of race, color, age, sex, religion, national origin, veteran status disability or any other protected

characteristic. This form is used to collect information so that we may analyze and monitor our equal opportunity efforts and to

complete aggregate statistical reports required by the federal government. This form is removed from the application prior to

the hiring supervisor’s review of the application, and is maintained separately from application and personnel files. Providing or

failing to provide this information does not adversely affect any consideration you may receive for employment or later

advancement in employment.

PLEASE PRINT

Date:

Position applied for:

Name:

Phone Number:

(Last)

(First)

(Middle)

Address:

(City)

(State)

(Zip Code)



Referred by:

Newspaper Ad

Company Employee

College/University



Internet/Website

Other (please specify)

Employee Office



Self-Referral



Gender:

Male

Female

Race/Ethnicity: Please mark one box



Hispanic or Latino

Black or African American (not Hispanic or Latino)



American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

(not Hispanic or Latino)



White (not Hispanic or Latino)

Asian (not Hispanic or Latino)



Two or more races (not Hispanic or Latino)

I decline to self-identify



Do you have a disability, a handicap or a medical condition that may affect your employment?

Yes

If yes, please specify and indicate any accommodation required of an employer for your condition.



Are you a protected veteran?

Yes

(Serving on active duty during a war or campaign for which a campaign badge was authorized)



Are you a Vietnam era veteran?

Yes



Are you a disabled veteran?

Yes

Do you have any religious beliefs which would require an employer to make accommodation



for you in work scheduling?

Yes

If yes, please specify:

Revised Jan. 2013

An Equal Opportunity Employer M/F/V/H

2013 Affirmative Action Information Form

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