Queensborough Community College
Affirmative Action, Pluralism & Diversity/ Compliance Office
Applicant Identification Form
Position applied for:
PVN #
Department:
Queensborough Community College of the City University of New York is committed to the principles of
equal opportunity and affirmative action in which personnel decisions are made on the basis of
qualifications without regard to race, color, sex, age, religion, national origin, ancestry, life style, sexual
orientation, disability or veteran status. In order for Queensborough Community College to comply with
Equal Opportunity Law and Regulations and to assess our recruitment efforts, it is necessary to solicit
information regarding ethnicity, sex and veteran status of all our applicants. This information is voluntary
and is used for statistical purposes only.
Referral Source
Walk-in
Employee
Government Agency
Relative
Private Agency
CUNY College
Internet
(identify)
Advertisement Source
Name of person who referred you (if applicable)
Other (identify)
Gender, Ethnicity and Veteran Identification
Please check one for each category:
Male
1.
Sex:
2.
Ethnic Origin:
Female
Hispanic
Not of Hispanic origin
Black
Italian American
Race:
Native American
White
(Indian, Alaskan)
(Not of Hispanic Origin)
Asian
Native Hawaiian or
Pacific Islander
2 or more races combined
3.
Veteran Status:
Recently Separated Veteran
Other Protected
Veteran
Armed Forces Service
Medal Veteran
Vietnam Era Veteran
 Newly Separated Veteran: A veteran 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 such discharge or release from active duty.
 Armed Service Medal Veteran: A veteran who while serving on active duty in the US military ground naval or air service, participated in a US
military operation for which an Armed Forces Service medal was awarded pursuant to E.O. 12985.
 Other Protected Veteran: A veteran 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, other than a specialized disabled veteran, Vietnam Vet or recently separated vet.
THANK YOU FOR YOUR COOPERATION
Please return this form to: Queensborough Community College Affirmative Action/Pluralism and Diversity Compliance Office, A-309
(In the self-addressed stamp envelope enclosed) or (email to: aapd@qcc.cuny.edu)
AAO:HP: 3/2007.