Affirmative Action Program - Self-Identification Form - Applicant Data Record

2. Required information:
4. Applicant Name, L, F, MI
5. Position Applied For*
7. Date
   Date
9. Voluntary Information:
   To comply with the regulations for equal employment opportunity and affirmative action (EEO/AA), we must track our applicants by gender and race/ethnicity and the position for which they applied. As a municipal employer, we comply with federal record keeping, reporting and affirmative action responsibilities. We are an organization that values diversity and encourages women and minorities to apply. For this reason, we invite you to indicate your gender and race/ethnicity below. This form is kept separate from your application, and will be processed/filed separately. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Responses will remain confidential within the Human Resources Department and will be used only for the necessary information to include in our Affirmative Action Program and reporting requirements to the federal government. When reported, data will not identify any specific individuals. Qualified applications are considered for each position and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or disability. Solely to help us comply with federal record keeping, reporting and other legal requirements, please fill out the survey.
11. AFFIRMATIVE ACTION SURVEY
13. Gender:

    Federal agencies require periodic reports on the sex, ethnicity, disability and veteran status of applicants. This data is for analysis and affirmative action only.

    1. Male
    2. Female
15. Race/Ethnic Identification (check one):
    Definitions of race/ethnicity are below (as defined by the Equal Employment Opportunity Commission).
17. Are you Hispanic of Latino?

    1. Yes
    2. No

    If you answered "Yes" you have completed this portion of the form.
19. If you answered "No" please select a race from the options listed:

    1. White (Not Hispanic or Latino)
    2. Black or African American (Not Hispanic or Latino)
    3. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
    4. Asian (Not Hispanic or Latino)
    5. American Indian or Alaska Native (Not Hispanic or Latino)
    6. Two or More Races (Not Hispanic or Latino)
    7. I do not wish to disclose
21. Check if any of the following are applicable:

    1. Vietnam Era Veteran
    2. Disabled Veteran
    3. Disabled Individual
25. APPLICANT DATA RECORD
26. Name of Website
27. Name of other publication
29. Referral source:

    1. City of Apopka website
    2. Other website
    3. Bulletin board
    4. Newspaper
    5. Other publication
    6. Employment agency
    7. Friend
    8. Relative
    9. City Employee
    10. Other
30. Employee Name
31. Other source:
33. Definitions of race/ethnic categories:
35. Hispanic or Latino
    A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race.
37. White (Not Hispanic or Latino)
    A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
39. Black or African American (Not Hispanic or Latino)
    A person having origins in any of the black racial groups of Africa.
41. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
    A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
43. Asian (Not Hispanic or Latino)
    A person having origins 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 Philippine Islands, Thailand, and Vietnam.
45. American Indian 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.
47. Two or More Races (Not Hispanic or Latino)
    All persons who identify with more than one of the above five races.
Leave This Blank:


49. Submit

* indicates a required field