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2. AFFIRMATIVE ACTION QUESTIONNAIRE

   This information is being gathered for affirmative action under Section 503 of the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.

   The purpose of this section is to assist in monitoring Affirmative Action Programs and to aid in complying with any required Governmental record keeping or periodic reporting. This information is not part of your employment/selection process. If you choose to provide the information, please complete the following:

4. Option (check if not selecting additional information and skip to the submit button)

   1. Prefer not to provide information
8. Title of job applied for:
9. Today's Date
   Today's Date
11. Sex

    1. Female
    2. Male
13. Race

    1. White –origins in Europe, North Africa, or Middle East
    2. Asian –origins in Far East, S.E. Asia, India, or Pacific Islands, China, Japan, Korea, Philippine Islands, Samoa
    3. Black –origins in Africa
    4. Hispanic –Mexican, Puerto Rican, Cuban, Central or South America
    5. American Indian – origins in North America, to include Alaska
15. VETERAN/U.S. MILITARY STATUS

    1. Non-Veteran
    2. Pre-Vietnam Veteran
    3. Pre-Vietnam veteran with service incurred disability
    4. Vietnam Era Veteran (8/5/64 – 5/7/75)
    5. Vietnam Era Veteran with service incurred disability
    6. Post Vietnam Veteran
    7. Post Vietnam Veteran with service incurred disability
17. ACTIVE NATIONAL GUARD OR RESERVIST

    1. No
    2. Yes
19. INFORMATION ON THIS PAGE WILL NOT BE KEPT IN YOUR PERSONNEL FILE
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21. 1. Receive an email copy of this form.
22. Email address

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23. Submit

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