Online Profile & Affirmative Action Form Page 3
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AFFIRMATIVE ACTION QUESTIONNAIRE
Advanced Health Education Center, Ltd is a Government contractor and is subject to
affirmative action obligations pursuant under Executive Order 11246 (minorities and
females), the Rehabilitation Act of 1973 (individuals with disabilities) and the Vietnam-Era
Veterans Readjustment Assistance Act of 1974 ("VEVRAA" - covered veterans). Our
company is requires to report sex and race/ethnic origin of applicants for employment.
Applicants are considered for all positions without regard to race, color, religion, gender,
national origin, age, marital or veteran status, or the presence of a non-job related medical
condition or disability. The information requested below is voluntary; failure to provide the
information will not jeopardize or adversely affects consideration of your employment.
Your cooperation is appreciated. The information obtained will be kept confidential and
may only be used in accordance with applicable laws. When data is reported, it will not
identify any specific individual.
Print Name (Last, First, Middle):
Date:
Date of Birth (mm/dd/yyyy):
Position sought:
Job Location:
Gender (Please check one):
Male
Female
Ethnic Group:
Hispanic / Latino (All persons of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin, regardless of race.)
Non Hispanic / Latino (If this is checked, please select from the racial groups below)
Racial Groups (If Non-Hispanic/Latino was selected above, please check one):
American Indian / Alaskan Native (All persons having origins in any of the original
peoples of North or South America, and who maintain cultural identification through
tribal affiliation or community attachment.)
Asian (All persons 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.)
Black / African American (All persons having origins in any of the Black racial groups
of Africa.)
Native Hawaiian / Other Pacific Islander (Any persons having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
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