EEO and Voluntary Self-ID Form

Address *

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Voluntary Information

Racial or Ethnic Group:

Hispanic/Latino (H) White/Caucasian (W) Black/African American (B) Asian (A) Native Hawaiian/Pacific Islander (P) American Indian/Alaskan Native (AI) Two or More Races (M)

Military Service – Voluntary Self‐Identification of Protected Veteran Status

I identify as one or more of the classifications of protected veteran listed I am not a protected Veteran

Choose to not self‐identify:

I choose not to answer

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do you know if you have a disability?

Please select one of the following options:

Yes, I have a disability, or have had one in the past No, I do not have a disability and have not had one in the past I do not want to answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Equal Employment Opportunity and Voluntary Self-ID Form – Licensed

Equal Employment Opportunity Form

Equal Employment Opportunity Form

Voluntary Information

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

How do you know if you have a disability?

Service Request