Eeo1 Form Editiable – Fill Out and Use This PDF

EEO-1 Self-Identification Form

The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

(If also a federal contractor/subcontractor – add this clause): As employers/government contractors, we also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, section 4212 of the Vietnam Era Veterans Readjustment Act of 1974 and Veterans Employment Opportunities Act (VEOA) of 1998.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.

(PLEASE PRINT)

Date:___________________________

Position(s) Applied For__________________________________________________________________

Referral Sources:	 Advertisement	 Friend		 Relative  Walk-In
	 Employment Agency		 Company Website  Other

Name_______________________________________________ Phone (			)_____________________
LAST	FIRST	MIDDLE
Address______________________________________________________________________________
NUMBER	STREET	CITY	STATE	ZIP CODE

EEO-1 Survey

If you wish to be identified, please sign below and complete the survey:

		Signed:__________________________________________
Check one:	 Male	 Female
		{Please Finish Survey on Back of Page}

EEO-1 Survey (Continued)

Ethnicity:

Are you Hispanic or Latino?

 No, I am not Hispanic or Latino.

 Yes, I am Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.

Race – IMPORTANT - Only complete this section if you checked “No, I am not Hispanic or Latino” in the Ethnicity section above:

What is your race? Select ONE of the following categorie(s):

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

 Black or African American – A person having origins in any of the Black racial groups of Africa.

 American Indian/Alaskan Native A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.

 Asian– A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

 Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

 Two or More Races – All persons who identify with more than one of the above five RACES.

(If federal contractor/subcontractor with affirmative action obligations – add the following section) Check if the following is applicable:

 Veteran - As defined under one or more of the following:

•served on active duty for a period of more than 180 days, and any part of which occurred between August 5, 1964 and May 7, 1975 and were discharged or released other than dishonorably; or,

•was discharged or released from active duty for a service connected disability if any part of the active duty was performed between August 5, 1964 and May 7, 1975; or

•who served on active duty in the U.S. military, ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge has been authorized (such as The Persian Gulf, El Salvador, Grenada, Lebanon, Panama, Southwest Asia, Haiti, Somalia & Bosnia); or

•one who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of discharge or release from active duty (recently separated veteran).

FOR PERSONNEL DEPARTMENT USE ONLY

Position(s) Applied For Is Open:  Yes  No

Position(s) Considered For:________________________________________Date___________________