Equal Employment Opportunity Self-Identification Form printable pdf download

EQUAL EMPLOYMENT OPPORTUNITY

SELF‐IDENTIFICATION FORM (completion of this form is voluntary)

Northern Plains Laboratory is an Equal Employment Opportunity/Affirmative Action Employer. Certain

laws and regulations require us to compile, maintain and report information on applicants and/or

employees. In order to comply with these laws and regulations, we are requesting your cooperation in

completing this voluntary EEO Self‐Identification Form.

The information will be kept confidential as required by regulations and will be processed and

maintained separately from your employment application forms. You will not be subjected to any

adverse treatment if you do not provide the information requested.

For the purpose of this form, please indicate the group in which you appear to belong, identify with,

or are regarded in the community as belonging.

Race and Ethnic Identification: Count yourself in one race/ethnic group

[ ] Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

[ ] White (Not Hispanic or Latino)

A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

[ ] Black or African American (Not Hispanic or Latino)

A person having origins in any of the black racial groups of Africa.

[ ] Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

A person having originis in nay of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

[ ] Asian (Not Hispanic or Latino)

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indican subcontinent including for

example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand and Vietnam.

[ ] American Indian or Alaska Native (Not Hispanic or Latino)

A person having origins in any of the original peoples of North or South American (including Central America) and who maintain

tribal affiliations or community attachment.

[ ] Two or More Races (Not Hispanic or Latino)

All persons who identify with more than one of the above five races.

[ ] I do not wish to provide this information

Gender

[ ] Female

[ ] Male

[ ] I do not wish to provide this information

Name: ____________________________________________________________

Signature: ___________________________________

Date: ____/____/____

self‐id EEO HR68.doc

Please return this form to:

HR‐68.001

Internal Support Coordinator

Northern Plains Laboratory

401 N 9

Street

Bismarck, ND 58501‐4507

Equal Employment Opportunity Self-Identification Form