Fill and Sign the Purpose and Routine Uses Form

YES NO Your response t o t his surv ey is v olunt ary . Please read each sect ion t horoughly and answ er each quest i on t o t he best of y our abilit y . Place t he applicable num ber f or each sect ion in t he box prov ided. SECTION A. RACE/ ETHNICITY 1 . A . M ex ican D. Cent ral A merican B. Puert o Rican E. Sout h A merican F. Ot her C. Cuban See Rev erse f or Disabilit y and Sex St at us inf ormat i on OMB No. 1115-0188 Applicant Survey PURPOSE AND ROUTINE USES PRIV ACY ACT INFORM ATION This inf ormat ion is used t o ev aluat e t he agency ' s recruit ment of minorit ies, w omen and persons w it h disabilit ies and t o help ensure t hat agency personn el pract ices meet t he requirement s of Federal Law . EFFECTS OF NONDISCLOSURE Prov iding t his inf ormat ion is v olunt ary . No indiv i dual personnel select ions are made based on t his inf ormat ion. Failure t o prov ide t his inf ormat ion w ill not af f ect y our chance f or employ ment . V acancy A nnouncement No. Posit ion, Tit le, Series, Gr ade Dut y Locat ion Name (Last , First , M I) (Please print ) Year of Birt h Social Securit y No. A re y ou a V et eran? (A person w ho w as separat ed w it h an honorable discharge or under honorable condit ions f rom act iv e dut y in t he armed f orces perf ormed f or more t han 1 8 0 consecut iv e day s, ot her t han f or t rai ning. ) INFORM ATION ON RACE/ ETHNICITY, SEX AND DISABILITY S TATUS 2 . 3 . 4 . Form G-942 (Rev. 10/17/00)Y Information Regarding Disclosure of Your Social Security Number Under Public Law 9 3 -5 7 9 , Section 7 (b) - Solicit at ion of y our Social Securit y Numbe r is aut horized under Ex ecut iv e Order 9 3 9 7 dat ed Nov ember 2 2 , 1 9 4 2 . Only aut horized agency of f icials w ill hav e access t o y our Social Securit y Number. American Indian or Alaskan Native - A person hav ing origin in any of t he original peoples of Nor t h A merica and w ho maint ains cult ural ident if icat ion t hrough communit y recognit ion or t ribal af f iliat ion . Asian or Pacific Islander - A person hav ing origins in any of t he original peoples of t he Far East , Sout heast A sia, and Indian subcont inent , or t he Pacif ic islands (f or ex ample, China, India, J apan, Korea, t he Philippines, Samoa, V iet nam). W hite, Not of Hispanic Origin - A person hav ing origins in any of t he original peoples of Europe, Nort h A f rica, or t he M iddle East . Does not include persons of M ex ican, Puert o Rican, Cuban, Cent ral or Sout h A merican cult ures or origins. (See Hispanic). A lso includes persons not in ot her cat egories. Hispanic - A person of M ex ican, Puert o Rican, Cuban, Cent ral or Sout h A merican, or ot her Spanish cult ures or origins. Does not include persons of Port uguese cult ure or origin. (Please indicat e " X " in appropriat e box below and place a " 5 " in t he box f or Sect ion A abov e. ) - Sect ion 1 3 0 2 , 3 3 0 1 , 3 3 0 4 , 7 2 0 1 of Tit le 5 of t he U. S. C. , 4 2 U. S. C. Sect ion 2 0 0 0 e and 2 9 U. S. C. Sect ion 7 9 1 . Authority - This inf ormat ion is prov ided pursuant t o Public Law 9 3 -5 7 9 (Priv acy A ct of 1 9 7 4 ), December 3 1 , 1 9 7 4 , f or indiv iduals complet ing Federal record s and f orms t hat solicit personal inf ormat ion. General 5 . Black or African American, Not of Hispanic Origin - a person hav ing origins in any of t he black racia l groups of A f rica. Does not include persons of M ex ican, Puert o Rican, Cuban, Cent ral or Sout h A merican or ot her Spanish cult ures or origins (See Hispanic). U.S. Department of Justice Immigration and Naturalization Service 2 . Female 1 . M ale A person is disabled if he or she has a phy sical or ment al impairment w hich subst ant ially limit s one o r more major lif e act iv it ies. If y ou hav e more t han one d isabilit y , choose t he one w hich result s in t he most subst ant ial limit at ion. 0 5 . I do not hav e a disabilit y . K. Federal Research Serv ice A . Friend in INS F. DOJ Career Opport unit ies B. Friend not in INS L. U. S. Employ ment Serv ice G. Of f ice of Personnel M anagment C. A gency Personnel Of f ice H. College or Univ ersit y M . New spaper N. Telev ision I. Radio E. A not her Federal A gency J . M ilit ary Inst allat ion Paperw ork Reduction Act Notice. A n agency may not conduct or sponsor an inf ormat i on collect ion and a person is not required t o respond t o a collect ion of inf ormat ion unless it display s a curr ent ly v alid OM B cont rol number. W e t ry t o creat e f orms and inst ruct ions t hat are accurat e, can be easily underst ood and w hich impose t he least possib le burden on y ou t o prov ide us w it h inf ommat ion. Of t en t his is dif f icult because some Immigrat ion law s are v ery complex . The est imat ed a v erage t ime t o complet e and f ile t his applicat ion is 4 minut es per applicat ion. If y ou hav e comment regarding t he accuracy of t his est imat e, or suggest ions f or making t his f orm simpler, y ou can w rit e t o t he Immigrat ion and Nat uralizat ion Serv ice, HQPDI, 4 2 5 I St reet , N. W . , Room 4 0 3 4 , W ash ingt on, DC 2 0 5 3 6 ; OM B No. 1 1 1 5 -0 1 8 8 . DO NOT M AIL YOUR COM PLETED APPLICATION TO THIS ADDRESS. SECTION B. SEX SECTION C. DISABILITY STATUS 0 6 . Handicap not list ed. 2 3 . Inabilit y t o read ordinary size print , no t correct able by glasses (can read ov ersize print o r use assit ing dev ice). 2 5 . Blind in bot h ey es (no usable v ision, may hav e some light percept ion). 2 8 . M issing one arm. 3 3 . M issing bot h hands or arm and one f oot or leg. 6 4 . Part ial paraly sis of bot h hands. 6 5 . Part ial paraly sis of bot h legs, any part . 6 7 . Part ial paraly sis of one side of t he body , including one arm and one leg. 6 8 . Part ial paraly sis of t hree or more major part s of t he body (arms and legs). 7 1 . Complet e paraly sis of bot h hands. 7 2 . Complet e paraly sis of one arm. 7 5 . Complet e paraly sis of legs. 7 7 . Complet e paraly sis of one side of body , i ncluding one arm and one leg. 7 8 . Complet e paraly sis of t hree or more major part s (arms and legs). 8 1 . Heart disease w it h rest rict ion or limit at ion of act iv it y . 8 2 . Conv ulsiv e disorder (e. g. epilepsy ). 8 6 . Pulmonary or respirat ory disorders (e. g. , t uberculosis, emphy sema, ast hma). 9 0 . M ent al ret ardat ion (a chronic and lif elon g condit ion inv olv ing a limit ed abilit y t o learn, to be educat ed, and t o be t rained f or usef ul product iv e employ ment as cert if ied by a st at e v ocat ional reha bilit at ion agency ). 9 1 . M ent al or emot ional illness (a hist ory of t reat ment f or ment al or emot ional problems). 9 2 . Sev ere dist ort ion of limbs and/ or spine ( e. g. dw arf ism, sev ere dist ort ion of t he back). SECTION D. ELIGIBILITY UNDER SPECIAL HIRING AUTHO RITY SECTION E. RECRUITM ENT INFORM ATION If y ou hav e been cert if ied by a st at e v ocat ional re habilit at ion agency or t he V et erans A dminist rat ion as eligible f or appoint ment t o a Federal posit ion under a speci al appoint ing aut horit y (Schedule A or B) because y ou are sev erely , phy sically or ment ally disabled, please a t t ach t he cert if icat ion t o y our applicat ion so t hat y ou may be giv en f ull considerat ion under t he special appoint i ng aut horit y . D. V acancy A nnouncement 1 6 . Tot al deaf ness in bot h ears, w it h or w it h out underst andable speech. 3 5 . M issing one hand or arm and one f oot or l eg. HOW DID YOU HEA R A BOUT THE POSITION FOR W HICH YOU A RE A PPLYING? (Check all box es w hich apply ). Form G-942 (Rev. 10/17/00)Y Page 2