Application For Employment Page 3
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5Personal Data
The information requested below will be kept confidential and will not affect your chances for employment. Your cooperation in
providing accurate information is important. This information is voluntary; you are not required to complete this form. Your
answers will be used for research purposes and to help insure equal employment opportunities. Please check the appropriate
response to each question. Thank-you for your assistance.
Name
Sex
Date of Birth
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Male
Female
Month
Day
Year
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1.
Black: (Not of Hispanic Origin): Persons having origins in any of the Black groups of Africa.
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2.
Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin,
regardless of race.
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3.
White: (Not Hispanic Origin): Persons having origins in any of the original peoples of Europe, North Africa, or the
Middle East.
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4.
American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who
maintain cultural identification through tribal affiliation or community recognition.
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5.
Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the
Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands,
and Samoa.
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6.
Other: (Specify).
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