Affirmative Action: Applicant Invitation to Self-Identify Gender and Race (EO 11246)

[Company Name] is an equal opportunity employer. As required by law, we must record certain information to be made a part of our affirmative action program.

Applicants for employment are invited to participate in the affirmative action program by reporting their status as a minority. In extending this invitation, we advise you that: (a) workers (applicants) are under no obligation to respond but may do so in the future if they choose; (b) responses will remain confidential within the human resource department; and (c) responses will be used only for the necessary information to include in our affirmative action program. We are a company that values diversity. We actively encourage women, minorities, veterans and disabled employees to apply.

Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Name:                                                                        

Position Applied for:

EEOC Race or Ethnicity (select one):

• Hispanic or Latino
• White (not Hispanic or Latino)
• Black or African American (not Hispanic or Latino)
• Native Hawaiian or Pacific Islander (not Hispanic or Latino)
• Asian (not Hispanic or Latino)
• American Indian or Alaskan Native (not Hispanic or Latino)
• Two or more races (not Hispanic or Latino)

Gender          

• Male
  
• Female
• I do not wish to self-identify

Signature: 

Date: 

How did you hear of our opening? 

• Employee referral    
• Company website 
• Job board    
• Social media   
• Radio/TV ad    
• Recruiter   
• Other – please explain:
  

*EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

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 Alaska 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 maintain tribal affiliation or community attachment.

Two or more races (not Hispanic or Latino) - All persons who identify with more than one of the above races.