EQUAL EMPLOYMENT OPPORTUNITY SURVEY
The government requires the Company to collect data on race, sex, and ethnic classification.
This self-identification form will be kept separately from your application and will not be a
basis for employment decisions. Your response is voluntary, and the information obtained
through this questionnaire shall be kept confidential.
(PLEASE PRINT CLEARLY)
NAME
DATE
POSITION DESIRED:
REFERRED BY:
SEX:
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Friend/Relative
Agency:
Walk-in
Male
Female
Other
WHITE (Not of Hispanic origin) - All persons having origins in any of the original peoples of
Europe, North America, North Africa, or the Middle East.
 BLACK (Not of Hispanic origin) - All persons having origins in any of the Black racial
groups of Africa.
 HISPANIC - All persons of Mexican, Puerto Rican, Cuban, Central South American or
other Spanish culture, regardless of race.
 ASIAN or PACIFIC ISLANDER - All persons having origins in any of the original
peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands.
This area includes, for example, China, Japan Korea, the Philippine Islands, and Somoa.
 AMERICAN INDIAN or ALASKAN NATIVE - All persons having origins in any of
the original peoples of North America and who maintain culture identification through
tribal affiliation or community recognition.