Form Rsa-1298a - Formulario De Recomendacion Page 5
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5RSA-1298AFORSLP (10-17) - Pagina 5
Programa de RSA?
Sí
NO
Opcional: Por favor, divulgue el nombre del familiar o compañero
íntimo.
FECHA PRESENTADO:
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of
1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504
of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the
Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits dis-
crimination in admissions, programs, services, activities, or employment based on race,
color, religion, sex, national origin, age, disability, genetics and retaliation. To request this
document in alternative format or for further information about this policy, call 1-800-563-
1221 Services: 7-1-1. • Free language assistance for DES services is available upon
request. Ayuda gratuita con traducciones relacionadas con los servicios del DES esta
disponible a solicitud del cliente.
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