Affirmative Action Supplement, Term Contract Form - Advertised Bid Proposal Page 3
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3PB-AAF.1 R5/26/09
State of New Jersey
Division of Public Contracts Equal Employment Opportunity Compliance
EMPLOYEE INFORMATION REPORT
IMPORTANT- READ INSTRUCTIONS ON BACK OF FORM CAREFULLY BEFORE COMPLETING FORM. TYPE OR PRINT IN SHARP BALLPOINT
PEN. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND SUBMIT THE REQUIRED $150.00 FEE MAY DELAY ISSUANCE OF YOUR
CERTIFICATE. DO NOT SUBMIT EEO-1 REPORT FOR SECTION B, ITEM 11.
SECTION A - COMPANY IDENTIFICATION
1. FID. NO. OR SOCIAL SECURITY
2. TYPE OF BUSINESS
3. TOTAL NO. OF EMPLOYEES IN THE ENTIRE COMPANY.
1. MFG
2. SERVICE
3. WHOLESALE
4. RETAIL
5. OTHER
4. COMPANY NAME
5. STREET
CITY
COUNTY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE)
7. CHECK ONE: IS THE COMPANY:
SINGLE-ESTABLISHMENT EMPLOYER
MULTI-ESTABLISHMENT EMPLOYER
8. IF MULTI-ESTABLISHMENT EMPLOYER, STATE THE NUMBER OF ESTABLISHMENTS IN NJ
9. TOTAL NUMBER OF EMPLOYEES AT ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT
10. PUBLIC AGENCY AWARDING CONTRACT
CITY
COUNTY
STATE
ZIP CODE
Official Use Only
DATE RECEIVED
INAUG DATE
ASSIGNED CERTIFICATION NUMBER
SECTION B - EMPLOYMENT DATA
11. Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns.
Where there are no employees in a particular category, enter a zero. Include ALL employees, not just those in minority/non-minority categories, in columns
1, 2, & 3. DO NOT SUBMIT AN EEO-1 REPORT.
PERMANENT MINORITY/NON-MINORITY EMPLOYEE BREAKDOWN
All Employees
***************** MALE ***************** **************** FEMALE ****************
JOB
Categories
COL. 2
COL. 3
Amer.
Amer.
Total
(Cols. 2 & 3)
MALE
FEMALE
Black
Hispanic
Indian
Asian
Non Min
Black
Hispanic
Indian
Asian
Non Min
Officials/Managers
Professionals
Technicians
Sales Workers
Office & Clerical
Craftworkers
(Skilled)
Operatives
(Semi-Skilled)
Laborers
(Unskilled)
Service Workers
Total
Total employment
From previous
Report (if any)
The data below shall NOT be included in the figures for the appropriate categories above.
Temporary & Part
Time Employees
14. IS THIS THE FIRST
12. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED?
15. IF NO, DATE LAST
Employee Information
REPORT SUBMITTED
Report Submitted?
13. DATES OF PAYROLL PERIOD USED
YES
NO
FROM:
TO:
SECTION C - SIGNATURE AND INDENTIFICATION
16. NAME OF PERSON COMPLETING FORM (Print or Type)
DATE
SIGNATURE
TITLE
17. ADDRESS NO. & STREET
CITY
COUNTY
STATE
ZIP CODE
PHONE, AREA CODE, NO.
I certify that the information on this form is true an correct.
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