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Equal Employment Opportunity Voluntary Self-Identification

We are an equal opportunity employer and do not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, or any other basis prohibited by federal, state, or local law. No question on this form is intended to secure information to be used for such discrimination.

We are required by federal regulations to report information as requested below. Your contribution of this information is completely voluntary. The information you provide is completely confidential and will be maintained separate from your personnel file and will not be used in a manner inconsistent with any applicable laws or regulations.

Gender Identification (select only one)
Race/Ethnic Identification
Disabled Veteran?

NOTE: A Disabled Veteran is an individual who is rated under Veterans Administration rules as having a disability of 30% or more, or a disability of 10% or 20% that qualified as a serious employment handicap, or has been released from active duty under a service connected disability.

Disabled Individual?

NOTE: A disabled individual is defined as an individual who has a mental or physical impairment which substantially limits one or more major life activities, has a record of such impairment, or who is perceived as having such an impairment.