Applicant Invitation to Self-Identify: Veteran Status and Demographic Data
Southern Illinois University Carbondale
Reporting regulations of the U.S. Equal Employment Opportunity Commission require that records be kept of the
number of applications by race, national origin, and sex. Although it is optional, you are encouraged to complete
and return this form.
Name: ___________________________________________________ Application Date: _____________________
Date of Birth: ________________________ Male: _____
Female: _____
Gender non-Conforming: _____
Department/Unit: ______________________________________________________________________________
Position Title: _________________________________________________________________________________
Position Number: ______________ Learned of Job From: ______________________________________________
Are you Hispanic or Latino?
Yes: _____
No: _____
Race (one or more):
_____ American Indian or Alaska Native
_____ Asian
_____ Black or African American
_____ Native Hawaiian or other Pacific Islander
_____ White
As a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as
amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), we are required to take affirmative
action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty
wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are
defined as follows:
A “disabled veteran” is one of the following:
o a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but
for the receipt of military retired pay would be entitled to compensation) under laws administered by
the Secretary of Veterans Affairs; or
o a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of
such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the
U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a
campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S.
military, ground, naval, or air service, participated in a United States military operation for which an
Armed Forces service medal was awarded pursuant to Executive Order 12985.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the
appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to
measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
_____ I identify as one or more of the classifications of protected veteran listed above
_____ I am not a protected veteran
_____ I choose not to respond
SIU Carbondale is an affirmative action/equal opportunity employer of individuals with disabilities and protected veterans
that strives to enhance its ability to develop a diverse faculty and staff and to increase its potential to serve a diverse student
population. All applications are welcomed and encouraged and will receive consideration.
Revised 8/2014