2. The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. Your employer invites you to self-identify gender and race/ ethnicity. Completion of this data is VOLUNTARY and will not affect your opportunity for employment, or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by Human Resources.
4. First Name
5. Last Name
7. Job Title
9. Please answer the following questions:
11. What is your gender?
    -- Select One --MaleFemaleNonbinary
13. What is your race/ethnicity?

    1. Hispanic or Latino
    2. White (not Hispanic or Latino)
    3. Black or African American
    4. Asian
    5. Native Hawaiian or other Pacific Islander
    6. American Indian or Alaskan Native
    7. Two or more races (not Hispanic or Latino)
    8. I do not wish to disclose

    Please check the box that describes the race/ethnicity category that you primarily identify.

15. Refusal to complete this form will not subject you to any adverse treatment. This form will be used for governmental reporting purposes only. If we have not received your completed form, the Company will interpret that to mean you have declined self-identification and will be required to obtain the necessary information from visual identification and/ or other available information.
17. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
19. Electronic Signature
20. Date
    Date
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field