Faa Form 54972 - Application For Employment With The Federal Aviation Administration - 2001 Page 12
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12RACE AND NATIONAL ORIGIN IDENTIFICATION
(Please read the instructions and Privacy Act Statement before completing form).
NAME: _________________________________________________________________________________
Last
First
MI
The categories below provide descriptions of race and national origins. Read the Definition of Category
descriptions and then blacken the circle next to the category with which you identify yourself. If you are of
mixed race and/or national origin, select the category with which you most closely identify yourself. Please
mark only one circle.
Name of
Male
Female
Definition of Category
Category
0 0
0 0
American Indian
A person having origins in any of the original peoples of North America,
or Alaskan
and who maintains cultural identification through community recognition
Native
or tribal affiliation.
0 0
0 0
Asian or Pacific
A person having origins in any of the original peoples of the Far East,
Islander
Southeast Asia, the Indian subcontinent, or the Pacific Islands. For
example, this area includes China, India, Japan, Korea, the Philippine
Islands, and Samoa.
0 0
0 0
Black, not of
A person having origins in any black racial groups of Africa. This does
Hispanic origin
not include persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish cultures or origins.
0 0
0 0
A person of Mexican, Puerto Rican, Cuban, Central or South American,
Hispanic
or other Spanish cultures or origins. This does not include persons of
Portuguese culture or origin.
0 0
0 0
White, not of
A person having origins in any of the original peoples of Europe, North
Hispanic origin
America, or the Middle East. This does not include persons of Mexican,
Puerto Rican, Cuban, Central or South American, or other Spanish
cultures or origins.
Privacy Act and Public Burden Statements
Solicitation of this information is authorized by section 2000e-16 of title 42, which requires that agency employment
practices be free from discrimination and provide equal employment opportunities for all, and by the Uniform Guidelines
on Employee Selection Procedures (1978), 43 FR 38297 et seq. (August 25, 1978), which requires agencies to examine
their employee selection procedures to identify any adverse impact those procedures have on women and minorities.
Solicitation of this information is in accordance with Department of Commerce Directive 15, "Race and Ethnic Standards
for Federal Statistics and Administrative Reporting." This information will be used to make statistical determinations
under the Federal Equal Opportunity Recruitment Program (5 USC 7201) and affirmative action programs under section
717 of the title VII of the Civil Rights Act of 1964 as amended. The furnishing of this data is voluntary; however, collection
of the information is essential to the design and maintenance of effective recruitment and preemployment processing
programs which will provide the best possible employment opportunities to all candidates. You are requested to furnish
your social security number (SSN) under the authority of Executive Order 9397 (November 22, 1943), which requires
agencies to use the SSN for the sake of economy and orderly administration in the maintenance of personnel records.
Furnishing of the SSN is voluntary; however, failure to provide the SSN may result in inaccurate statistical records.
The public reporting burden for completing this form is estimated to vary from 1 to 3 minutes with an average of 2
minutes. The estimate includes time for reviewing instructions, gathering data needed, and completing and reviewing
entries. Send comments regarding the burden estimate or any other aspect of this form, including suggestions for
reducing the burden to: Federal Aviation Administration, Office of Human Resource Management, 800 Independence
Avenue, SW, Washington D.C. 20591.
SSN: _______-______-__________
FAA Form CAPS RNO (3/99)
11
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