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EEO Self-Identification Form

This Equal Employment Opportunity (EEO) Self-Identification form serves to fulfill the governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. This is a voluntary self-identification form used to collect confidential gender and ethnic information. All information collected is kept strictly confidential and is completely voluntary.

Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, or other protected characteristic.

The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may be used only in accordance with the provisions of applicable laws, Executive Orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

This detachable form will be kept in a confidential file separate from your application for employment.

Name (Last, First, MI): ____________________________________________________________________

Street Address: ________________________________________________________________________

City, State, ZIP Code: _____________________________________________________________________

Position Applied For: ________________________    Date Applied: ____________

Gender Identification (check one):   ____Female   ____Male

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