Applicant Affirmative Action Plan Voluntary Survey Template - City Of Newport R.l. Incorporated
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1Applicant Affirmative Action Plan Voluntary Survey
In our efforts to maintain an affirmative action program and to collect information regarding the race, sex,
national origin, disability, or veteran status of applicants we ask that you kindly assist us in our
governmental recordkeeping requirements.
We would appreciate your completion of this data form.
Your cooperation is voluntary.
The
information supplied will be kept confidential and will be used to improve our recruiting efforts
and support our commitment to diversity in the workplace.
If you choose to volunteer the requested information, the data will be physically separated from the
remainder of the job application before the application is considered for possible employment. The
information will be kept in a confidential file separate from your application for employment.
Thank you for your cooperation!
Name
Date
Position applied for
Sex:
Male
Female
Age Group:
21 – 30 Yrs.
31 – 40 Yrs.
41 – 50 Yrs.
51 – 60 Yrs.
Ethnic Background:
American Indian/Alaskan Native
Asian/Pacific Islander
Black
Hispanic
White
Other
Disabled:
Yes
No
Veteran Status: Veteran:
Yes
No
If yes, period of service: From
To
Are you a disabled veteran?
Yes
No
Referral Source:
Friend
Walk-in
Relative
Employment Interest Card
Employment Agency
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State Employment Service
College/University Job Placement Office
City Employee
Social Service Agency/Organization
Web Site
Other
We Are An Equal Opportunity/Affirmative Action Employer
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Parent category: Business