Pa ‘TX Result Report 02/19/2015 15:55 Serial No. AoPoo110000S1 Te: = 205620 Destination | Start Tine | Time Prints | Result} Note Tasaaee ax 4 [owas [moo [og Yoke! a oi, aR ay Te gD ETE EP ia URE Result OK: Connunication OK, $-OK: Stop Communication, PH-OFF: Power Switch OFF, ‘TEL: RX fron TEL, NG: Other Error, Cont: Continue, No Ans: No Answer, Refuse: Receipt Refused, Busy: Busy, M-FUll:Menory Full, LovR:Receiving ‘length Over, POUR:Receiving page Over, FiL:File Error, Dc:Decode Error, MON:MON Response Error, DSN:DSN Response Error. anit fe Pack, Ship & Print Contor 2200 Avenn pris “Sine Ves Cate Scand WOEE Be IE STEP ae 240-03 MIA FAX TRANSMISSION OF PEesennel Manageme ur pate: _2/ tt Jrors ro: U.S. OFF 2o2 co: Re NUMBER OF PAGES INCLUDING THIS PAGE: 2 Wabalte: www packehipnprintcomU.S. Office of Personnel Management ETHNICITY AND RACE IDENTIFICATION ‘Guide fo Personnel Data Standards (Please read the Privacy Act Statoment and instructions before completing form ) ‘Name (Last, First, Middle Initial) ‘Social Security Number Birthdate (Month and Year) Borden, Eric, Anthony 219-17-9768 121978 ‘Agency Use Only Privacy Act Statement a Site Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance with the Office of Management and Budget's 1997 Revisions to the Standards for the Classification of Federal Data on Race land Ethnicity. Providing this information is voluntary and has no impact on your employment status, but in the instance (of missing information, your employing agency will attempt to identify your race and ethnicity by visual observation, This information is used as necessary to plan for equal employment opportunity throughout the Federal government. It is also used by the U. S. Office of Personnel Management or employing agency maintaining the records to locate Individuals for personnel research or survey response and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies. Social Security Number (SSN) is requested under the authority of Executive Order $397, which requires SSN be used for the purpose of uniform, orderly administration of personnel records. Providing this information is voluntary and failure to do so wil have no effect on your employment status. If SSN is not provided, however, other agency sources may be used to obtain tt ‘Specific Instructions: The two questons below are designed to ently your ethnly and race, Regardless of your answer to ‘Question 1, goto question 2 ‘Question 1. Are You Hispanic or Latino? (A parson of Cuban, Mexican, Puerto Rican, South or Genial American, Sher Spanish cure or origin, regaress of race) ves BNO ‘Question 2. Please select the racial category or categories wth which you most elosely ently by placing an °K" inthe appropriate box. Check as many a3 app. icfackasiasy enact DEFINITION OF CATEGORY 59 American indian or Alaska Native ‘A person having origins in any of the orginal peoples of North and South America (including Central America), and who maintains tibal afliaton or community attachment, Asian ‘A person having origins in any ofthe original peoples of the Far East, Southeast ‘sia, of the Indian subcontinent including, for example, Cambodia, China. India, ‘Jepan, Korea, Malaysia, Pakistan, the Philippine Isiancs, Thailand, end Vietnam. 1 Black or Atican American ‘A person having oxgins in any ofthe black racial groups of Africa. Native Hawaiian or Other Pacific Islander | A person having origins n any ofthe orginal peoples of Hawaii, Guam, Samoa, or other Pacifie Islands B wnite ‘A person having origins in eny ofthe orginal peoples of Europe, the Middle East, or North Attica, ‘Standard Form 181 Revised August 2005 Previous editions not usable 42USC. Section 20000-16 NSN 7540.01-000-3446