Affirmative action survey

The intent of asking for the information below is to assist the College in meeting its commitments to equal opportunity and affirmative action. Completing and returning this form is purely VOLUNTARY on your part and will have absolutely no effect on the status of your employment application.

Date:
Position applied for:
Your name: (full name please)
For this form to accomplish its purpose, each area must be completed, especially your name.
Gender: Female 
Male
Check all that apply:
African-American, Non-Hispanic - A U.S. citizen having origins in any of the Black racial groups of Africa.
American Indian or Alaskan Native - A U.S. citizen having origins in any of the original people of North America and who maintains identification through tribal affiliation or community recognition.
Asian or Pacific Islander - A U.S. citizen 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.
Hispanic - A U.S. citizen of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
White, Non-Hispanic - A U.S. citizen having origins in any of the original peoples of Europe, North Africa or the Middle East.
Handicapped - "Handicapped" means any person who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) is regarded as having such an impairment.
Vietnam Era Veteran - Any veteran of the armed services who between Aug. 5, 1964, and May 7, 1975, served on active duty for at least 181 consecutive days or was discharged sooner because of a service-related disability.
Please indicate how you learned of this position:
Goshen College personnel posting
Personal contact
Professional journal
Journal name: 
Newspaper advertisement
Newspaper: 
Placement service
Name of service: 
Other: