Employee Self-ID Document

EMPLOYEE SELF-ID DOCUMENT

Employer Name:    Employee ID:

Personal Information

Position Information

Reporting Manager:    Start Date:    Salary: $

Employment History (Most Recent First)

Education

Graduation Date:    Major / Field:

References (Professional)

Self-Identification (Voluntary)

The following information is requested for affirmative action and equal employment opportunity recordkeeping. Completion is voluntary and will be kept confidential and maintained separately from personnel files. Select all that apply.

Hispanic or Latino    Not Hispanic or Latino    Prefer not to disclose

American Indian or Alaska Native    Asian    Black or African American    Native Hawaiian or Other Pacific Islander    White    Other:

Female    Male    Non-binary / Third gender    Prefer not to disclose    Other:

Veteran    Disabled Veteran    Not a Veteran    Prefer not to disclose

Yes, I have a disability    No    Prefer not to disclose

Legal Disclosures & Company Statements

At-Will Employment: I acknowledge that, unless otherwise specified by a written agreement signed by an authorized representative of the employer, my employment is at-will and may be terminated by either party at any time, with or without cause or notice. This acknowledgement does not alter any at-will relationship unless expressly set forth in a signed written agreement.

Equal Employment Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected characteristic. This Self-ID information is used for statutory reporting, affirmative action, and internal analysis and will not be used as a basis for employment decisions.

Confidentiality: Self-identification information will be treated as confidential and stored separately from personnel files. Access is limited to authorized personnel for legitimate business purposes and compliance reporting.

Authorization and Certification

Authorization to Verify and Contact: I authorize the employer and its agents to contact former employers, educational institutions, references, and other entities necessary to verify the information provided. I further authorize the procurement of background checks, criminal records checks, and other screening as permitted by law. I release those parties from liability for providing such information in good faith.

Applicant Certification: I certify under penalty of perjury that the information provided on this Employee Self-ID Document is true, complete, and correct to the best of my knowledge. I understand that any false statements or omissions may result in disciplinary action up to and including termination of employment. Completion of this form is voluntary where indicated; however, refusal to provide certain demographic data will not subject me to adverse action.

Acknowledgement: I acknowledge and certify the above statements.

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