Self Identify Form

This Company prepares affirmative action plans that cover females, minorities, and other certain individuals. This survey is meant to help the company fulfill certain objectives in these affirmative action plans.

PLEASE NOTE: You are not required to complete any part of this form. The decision not to complete this form will not affect any opportunity for employment or any benefits with the company. Any information provided in this survey will be kept in confidence and will not be used in any way that may adversely affect your employment with this company.

Name:_________________________

Date:_________________________

Position you are applying for:____________________________________

How were you referred to the company:______________________________


AFFIRMATIVE ACTION RELATED DATA (Please check the appropriate boxes)

Race/Ethnic Origin:

Hispanic or Latino
White (Not Hispanic/Latino)
Black or African-American (Not Hispanic/Latino)
Native Hawaiian or Other Pacific Islander (Not Hispanic/Latino)
Asian (Not Hispanic/Latino)
American Indian or Alaskan Native (Not Hispanic/Latino)
Two or more races (Not Hispanic/Latino)

Sex:

Male
Female

Instructions: Please print off this form and return via fax at 419-897-6839.