| 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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| 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?
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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.
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