Voca Grant Application - New Hampshire Department Of Justice Page 16

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62
CIVIL RIGHTS INFORMATION FORM*
A. Race or National Origin
Number
White
______
African-American
______
Hispanic
______
Asian or Pacific Islander
______
American Indian or Alaskan Native
______
Total
______
B. Sex
Number
Male
______
Female
______
Total
______
C. Disability
Number
Yes
______
No
______
Total
______
D. Age
Number
0-12 years
______
13-17 years
______
18-25 years
______
26-40 years
______
41-60 years
______
61 + years
______
Total
______
* This Civil Rights Information form should be returned when you submit your annual
VOCA Performance Report.
Revised 10/99

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