Fill and Sign the Employee Self Identification Form

EMPLOYEE SELF - IDENTIFICATION FORM TO BE COMPLETED BY ALL NEW EMPLOYEES AND RETURNED TO EMPLOYING DEPARTMENT. EMPLOYING DEPARTMENT: PLEASE FORWARD TO HUMAN RESOURCES Name:       Department:       (Please Print) Social Security #:       Date:       { Insert Company Name } is an equal opportunity employer committed to the policies and principles of affirmative action. Providing this information is optional. Failure to submit data will not in any way affect your present or future employment. The information provided will remain confidential and be used primarily for government reporting purposes. GENERAL INFORMATION - PART I SEX/GENDER : (Check one) Female Male RACIAL/ETHNIC HERITAGE : (Check only one) If you do not provide the racial/ethnic heritage information, federal regulations stipulate that a visual survey or post - employment records may be used to acquire racial/ethnic heritage information necessary for the completion of affirmative action records. 1. Black, not of Hispanic origin: A person having origins in any of the Black racial groups of Africa. 2. Asian or Pacific Islander: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa. 3. American Indian or Alaskan Native: A person having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. 4. Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. 5. White, not of Hispanic Origin: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. VETERANS STATUS : (Check all that apply) A. I am not a veteran of the U.S. Armed Forces. B. I am a veteran of the U.S. Armed Forces. C. I am a Vietnam Era Veteran. For federal reporting purposes, a Vietnam Era Veteran is defined as a veteran, any part of whose active military, naval, or air service was during the period of August 5, 1964, through May 7, 1975 who (a) served on active duty for a period of more than 180 days and was discharged or released therefrom with other than a dishonorable discharge or (b) was discharged or released from active duty because of a service - connected disability. D. I am a spouse of a disabled wartime veteran whose disability is at least 70% and is traceable to war service. E. I am an unremarried spouse of a veteran killed in action or a veteran who died of a service - connected disability. DISABILITY/HANDICAP : (Check one) Yes No The Rehabilitation Act of 1973, as amended, defines an "Individual with a Disability" for the purposes of the program as any person who (a) has a physical or mental impairment which substantially limits one or more of such person's major life activities; (b) has a record of such impairments; or (c) is regarded as having such impairment.