Form Aa302 - Employee Information Report

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Form AA302
Rev. 10/08
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 NON-REFUNDABLE FEE MAY DELAY ISSUANCE OF YOUR CERTIFICATE.
DO NOT SUBMIT EEO-1 REPORT FOR SECTION B, ITEM 11. For Instructions on completing the Form, go to:
SECTION A - COMPANY IDENTIFICATION
1. FID. NO. OR SOCIAL SECURITY
2. TYPE OF BUSINESS
3. TOTAL NO. EMPLOYEES IN THE ENTIRE
1. MFG
2. SERVICE
3. WHOLESALE
COMPANY
4. RETAIL
5. OTHER
4. COMPANY NAME
5. STREET
CITY
COUNTY
STATE
ZIP CODE
6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE)
CITY
STATE
ZIP CODE
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.
ALL EMPLOYEES
PERMANENT MINORITY/NON-MINORITY EMPLOYEE BREAKDOWN
JOB
COL. 1
COL. 2
COL. 3
********* MALE************************************FEMALE**********************
TOTAL
MALE
FEMALE
CATEGORIES
AMER.
NON
AMER.
NON
(Cols.2 &3)
BLACK HISPANIC INDIAN ASIAN
MIN.
BLACK
HISPANIC INDIAN
ASIAN
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)
Temporary & Part-
be included in the figures for the appropriate categories above.
The data below shall
NOT
Time Employees
12. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED?
14. IS THIS THE FIRST
15. IF NO, DATE LAST
1. Visual Survey
2. Employment Record
3. Other (Specify)
Employee Information
R EPORT SUBMITTED
Report Submitted?
MO. DAY YEAR
13. DATES OF PAYROLL PERIOD USED
From:
To:
1. YES
2. NO
SECTION C - SIGNATURE AND IDENTIFICATION
16. NAME OF PERSON COMPLETING FORM (Print or Type)
SIGNATURE
TITLE
DATE
MO DAY YEAR
17. ADDRESS NO. & STREET
CITY
COUNTY
STATE
ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)
-
-
I certify that the information on this Form is true and correct.

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