Voluntary Application Eeo Self-Identification Form printable pdf download

Return to:

or mail to: BNC National Bank

Attn: C. Froelich

322 E Main Ave

Bismarck, ND 58501

APPLICANT/EMPLOYEE VOLUNTARY EEO SELF-IDENTIFICATION FORM

Position for which you are applying or current position: ______________________

BNC National Bank is an equal opportunity employer. BNC National Bank is subject to certain governmental

recordkeeping and reporting requirements for the administration of civil rights laws and regulations.

To comply

with these laws, we invite you to voluntarily self-identify your gender and race or ethnicity. Self-identification is

voluntary and there will be no negative consequences if you elect not to disclose this information. The information

obtained will be kept confidential and will only be used in accordance with the provisions of applicable laws,

executive orders, and regulations. When reported, the data will not identify any specific individual.

BNC National Bank does not discriminate on the basis of race, color, religion, creed, sex, sexual orientation, marital

status, genetic information, national origin, age, disability, veteran status, or any other characteristic protected by

applicable law.

Please print legibly in blue or black ink.

Name First:

Middle:

Last:

Address:

City:

State:______ Zip:

Current Work Site (if applicable):

_____

Decline to disclose

GENDER: ____ Male

____ Female

ETHNICITY:

Check: ___ YES or ___ NO: Are you Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South

or Central American, or other Spanish culture or origin regardless of race)?

IF YOU ANSWERED “YES” TO THE QUESTION ABOVE, PLEASE DO NOT FILL OUT THE

REMAINDER OF THIS FORM.

IF YOUANSWERED “NO” TO THE QUESTION ABOVE, PLEASE CHECK ONE DESCRIPTION

BELOW:

RACE:

_____ White (not Hispanic or Latino) – A person having origins in any of the original peoples of Europe,

North Africa, or the Middle East;

_____ Black or African American (Not Hispanic or Latino) – A person having origins in any of the Black

racial groups of Africa;

_____ 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;

_____ 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;

_____ American Indian or Alaskan 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 maintains

tribal affiliation or community recognition; and

Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of

_____

the above five races.

Voluntary Application Eeo Self-Identification Form

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