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LOUISIANA NATIONAL GUARD RACE AND ETHNICITY IDENTIFICATION

(PRINT OR TYPE EACH SECTION CLEARLY)

PRIVACY ACT STATEMENT

Race and Ethnicity information is requested under the authority of 42 USC Section 2000e-16. Providing this information is voluntary and has no impact on your employment status. This information is gathered in conjunction with diversity programs within the Louisiana National Guard. It may also be used to locate individuals for personnel research or survey response and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies. Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be used for the purpose of uniform, orderly administration of personnel records. Providing this information is voluntary and failure to do so will have no effect on your employment status.

A. APPLICANT INFORMATION

B. POSITION INFORMATION

C. ACKNOWLEDGEMENT

Please read and initial the statements below before proceeding to Section D

STATEMENT

INITIALS

1.I understand that I DO NOT have to provide the information in Section D.

2.I understand that providing the information requested in Section D is voluntary.

3.I understand that providing the information in Section D below has no impact on my selection or non-selection for a vacancy.

D. RACE AND ETHNICITY

CHECK ONLY ONE OF THE STATEMENTS BELOW

I agree to furnish the Louisiana National Guard with information regarding my race and ethnicity. (proceed to Question 1)

I DO NOT agree to furnish the Louisiana National Guard with information regarding my race and ethnicity. (proceed to Section F)

Question 1	Are you Hispanic or Latino?	Yes	No

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

	Question 2	Please select the racial origin(s) with which you most closely identify by placing an “X” in the
		appropriate box. Check as many as apply.
		RACIAL ORIGIN	DEFINITION OF ORIGIN
	(check as many as apply)
	American Indian or Alaska Native		A person having origins in any of the original peoples of North and South America (including
			Central America), and who maintains tribal affiliation or community attachment.
			A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
	Asian		Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea,
			Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
	Black or African American		A person having origins in any of the black racial groups of Africa.
	Native Hawaiian or Pacific Islander		A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other
			Pacific Islands.
	White		A person having origins in any of the original peoples of Europe, the Middle East, or North
			Africa.
			F. SIGNATURE

I certify that the information contained in this form is true and accurate. I understand that any false claims or statements have the potential to prevent a candidate from being considered for employment with, and/or nullify the selection or appointment to a position within, the Louisiana National Guard

LANG FORM 335-8 (20091001)