UNIVERSITY OF CALIFORNIA, DAVIS
CONFIDENTIAL APPLICANT SURVEY
PLEASE PRINT
NAME (Last, First, Middle Initial)
CITY
STATE
DATE
ZIP
VACANCY LISTING (VL) # AND TITLE OF POSITION
FOR WHICH YOU APPLIED
PRIVACY NOTIFICATION
The State of California Information Practices Act of 1977 requires the University to provide the following information to individuals who are
asked to supply personal information about themselves. Information is requested on this form in compliance with certain laws and
regulations as described on the reverse, and will be used to conduct statistical analysis in accordance with these guidelines. Furnishing
the information requested on this form is voluntary. Individuals have the right to review their own records in accordance with University
personnel policy and collective bargaining agreements. The officials responsible for maintaining the information obtained on these forms
are the Assistant Vice President--Human Resources, Assistant Vice President--Academic Advancement, and campus Provost and
Executive Vice Chancellor/Affirmative Action Officer.
SEX: _____ Female
_____ Male
ETHNICITY (Please check one space only)
AMERICAN INDIAN
___ (C) American Indian/Alaskan Native (specify tribal affiliation) _____________________________
ASIAN/PACIFIC ISLANDER
___ (2) Chinese/Chinese-American
___ (R) East Indian/Pakistani
___ (L) Filipino/Pilipino
___ (B) Japanese/Japanese-American
___ (X) Other Asian (including the Far East, Korea, Southeast Asian or Pacific Islands, Samoa)
BLACK
___ (A)
Black/African-American (not of Hispanic origin)
HISPANIC (including Black individuals whose origins are Hispanic)
___ (5) Latin-American/Latino (including Cuban and Puerto Rican)
___ (E) Mexican/Mexican-American/Chicano
___ (W) Other Spanish/Spanish-American
WHITE
___ (F)
White/Caucasian (including the Middle East)
RECRUITMENT SOURCE (Please indicate how you learned about this position)
A.
B.
C.
D.
E.
F.
___
___
___
___
___
___
Publication Advertisement (specify) ______________________________
Professional Organization
UC Davis Position Announcement
General Inquiry
Friend or Colleague
Other (specify) ______________________________________________
Last Revised 5/7/2004
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UNIVERSITY OF CALIFORNIA, DAVIS
CONFIDENTIAL APPLICANT SURVEY
The United States Department of Labor requires the University of California to produce periodic reports on
applicants for positions at UC Davis, providing this data is voluntary. Neither this form nor its contents will
be used in determining or judging eligibility or qualification for employment. Thank you for your
cooperation.
The University of California prohibits discrimination against or harassment of any person employed by or
seeking employment with the University on the basis of race, color, national origin, religion, sex, physical
or mental disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status,
age, sexual orientation, citizenship, or status as a covered veteran (special disabled veteran, Vietnam era
veteran, or any other veteran who served on active duty during a war or in a campaign or expedition for
which a campaign badge has been authorized).
The University of California is an affirmative action/equal opportunity employer. The University undertakes
affirmative action to assure equal employment opportunity for underutilized minorities and women, for
persons with disabilities, and for special disabled veterans, Vietnam era veterans, and any other veterans
who served on active duty during a war or in a campaign or expedition for which a campaign badge has
been authorized.
University policy is intended to be consistent with the provisions of applicable State and Federal laws.
Inquiries regarding the University's equal employment opportunity policies may be directed to Anil Chandra
or Sylvia Reyes, Staff Affirmative Action/EEO and Diversity, TB 122, One Shields Ave., Davis, CA 95616,
(530) 752-6030 or FAX (530) 752-6793. Speech or hearing impaired persons may dial (530) 752-7320
(TDD).
Last Revised 5/7/2004
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