Applicant Voluntary Self-Disclosure Submittal Form

The employers we represent are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite the applicant to voluntarily self-identify their race/ethnicity, sex and veteran status.   Submission of the self identification information is voluntary and refusal to provide it will not subject you to any adverse treatment or influence in the hiring process. The information obtained will be kept confidential and may only be used 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

Job Requisition ID:
Full Name:
Last First Initials
     
Position Applied For Date Applied:
Location:

Gender:

RACE/ETHNICITY
Please mark on box that describes the race/ethnicity category with which you primarily indetify:
Hispanic or Latino A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of ethnicity.A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of ethnicity. A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of ethnicity.
White A person having origins in any of the original peoples of Europe, North Africa or the Middle East.
Black or African American A person having origins in any of the black ethnic groups of Africa.
Native Hawaiian or Other Pacific Islander A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian A person having origins in any of the peoples of Hawaii, Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand and Vietnam.

American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the five races listed above.

Decline to state  

VETERAN STATUS – please check all that apply:
No Veteran Status

  
Special Disabled Veteran (A) A veteran who is entitled to compensation (or who, but for receipt of military retired pay, would be entitled to compensation) under laws administered by the Dept. of Veteran Affairs for a disability rated at 10 or 20% in the case of a veteran who has been determined to have a serious employment disability OR

(B) A person who was discharged or released from active duty because of a service-connected disability

Vietnam A person who:

(A) Served on active duty for a period of time more than 180 days, any part of which occurred between 8/10/64 and 5/07/75 and was discharged or released with other than a dishonorable discharge OR

(B) Was discharged or released from active duty for a service connected disability if any part of such active duty was performed between 8/10/64 and 5/07/75 OR

(C) Served on active duty for more than 180 days and served in the Republic of Vietnam between 2/28/61 and 5/07/75.

Other Protected Veteran A veteran in one of the following groups:

(A) Veterans who served in a “war”;

(B) Veterans whose service in a campaign or expedition for which a campaign badge has been authorized or an expeditionary medal has been awarded. This includes a number of engagements.

Disclosure:
For each applicant where the prospective employer needs us to provide documentation and data related to OFCCP, we request these applicants to provide this data by filling form -OFCCP (Applicant Self- Disclosure Form) along with their application for the job requisition they were solicited or applied for. The data collected for this purpose will be kept confidential and may only be used in accordance of the permissible laws, executive orders and regulations, including those require these information to be summarized and reported to the federal government for civil rights enforcement. When reported data will not identify any specific individual.