| First Name * |
|  | Email |
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| Middle Initial |
| | Home Phone * |
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| Last Name * |
| | Work Phone |
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| Address |
| | Other Phone |
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| City |
| | How did you find us? |
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| State |
| | Specific Source |
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| Zip |
| | Preferred shift |
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2
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4
5 |
| Country |
| | Previous or Current
Employee? |
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| Voluntary Self-Identification. Confidential - for statistical use only. |
| Reason for the request: VSEA is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, VSEA invites candidates to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those which require the information be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. |
The following three questions are optional. |
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Gender
(optional) |
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Ethnicity
(optional) | 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?
Unknown or Declined
Yes, Hispanic or Latino
No, not Hispanic or Latino |
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Race
(optional) | - Answer the following question ONLY if you selected "No, not Hispanic or Latino" above -
Please check one of the descriptions below corresponding to the ethinic group with which you most identify.
Unknown or Declined
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 an 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 Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islnads, 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 fo the above five races |