VOLUNTARY APPLICANT

SELF IDENTIFICATION SURVEY

This form will be confidentially retained separate and apart from your personnel file in the Human Resources office.

The information which applicants provide does not at all affect prospects for employment and is
confidential. It is, however, very important to us. For any statistical analysis to be meaningful, we
must have information on as many applicants as possible and it is just as important to collect
information from men and non-minority groups as it is to obtain it from women and minority groups.
We understand that some applicants will find this request intrusive. However, please be advised that
we are required by the government to keep such records and perform such analyses; your cooperation
will allow us to be accurate.
The categories listed below are those used by the U.S. Bureau of Census and Department of Labor,
and are the only options currently available to you at this time for Federal reporting purposes.
GENDER:
CHECK ONLY ONE:
MALE
FEMALE

ETHINICITY:
CHECK ONLY ONE:
Hispanic or Latino

White (not Hispanic or

Latino)

American Indian /
Alaska Native (not
Hispanic or Latino)

African American
(not Hispanic or
Latino)

Native Hawaiian or
other Pacific
Islander (not
Hispanic or Latino)

Asian (not
Hispanic or
Latino
Two or More
Races (Not
Hispanic or
Latino)

PRINT NAME___________________________________________________ DATE____________________

POSITION APPLIED FOR_____________________________________________________________

SEAKR Engineering
An equal opportunity employer,
promoting workplace diversity
2014