Employment Application & Personnel Record Form - Eeo Employer Page 4

Applicant: DO NOT WRITE ON THIS PAGE

Interviewer's Comments

To be completed by crew leader/supervisor, only after employee is hired,

Organization Code: __________/__________/__________ Starting Date: __________________________

Occupation Code/Description: ____________________________________________________________

Rate of Pay per hr/wk: _____________________________ Date of Birth___________________________

Sex:

Race:

White

Black

Hispanic

Asian

American Indian

Comments:

Federal law forbids discrimination based on age, sex, race, religion, national origin, physical or mental handicap

or disability. This information is obtained solely for federal statistical reporting requirements. Obtain date

of birth from employee and circle employee's race and sex from visual observation.

Crew Leader's or Supervisor's Signature

Date

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Parent category: Business