Affirmative Action Form

* Required Information

Section 1: General Applicant Information

Name *

Date *

Position Applied for *

Section 2: Please check all that apply (see directions below)

Race or Ethnicity

Hispanic or latino

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

American Indian or Alaskan Native

Two or more races

Gender

Female

Male

Veteran Status

Vietnam Era Veteran

Special Disabled Veteran

Other Protected Veteran

Recently Separated Veteran

Armed GForces Service Medal Veterans

Not a Veteran

Individual with disabilities *

Yes

No

Do you wish to self identify?

Yes

No

Applicant's Name *

Today's Date