Race and Ethnicity Form

First Name:
Last Name:
Middle Initial:
The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. 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 only be used under the provisions of applicable laws, executive orders, and regulations, including those which 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.

I do not wish to respond.

Initials:
Date:

Please place an (x) in the appropriate box if you wish to respond:

Sex:
Race:
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having roots in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines, Thailand, and Vietnam.
Native American or Alaska Native (Not Hispanic or Latino) - 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 identify with more than one of the above five races.
Signature of Applicant:
Date:

Submit & Continue to Employment Application

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