Equal Employment Opportunity Information Sheet

As mandated by Federal Law, we are required to develop and maintain an Affirmative Action plan.  Therefore, we ask you to complete this form to assist us in Equal Employment Opportunity record keeping.  Completing this form is on a voluntary basis.  This form is kept separate from your personnel file in the Corporate Human Resources Department.

Name:  							Marital Status:  _____ single  _____ married

U.S. Citizen:  _____ Yes    _____ No        Sex:  _____ M  _____ F	Birth Date:   _____/_____/_____

Ethnic Origin:

_____ 1.  Caucasian     		_____ 3.  Hispanic		_____ 5.  American Indian /										  Alaskan Native   

_____ 2.  African American      	_____ 4.  Asian / Pacific Island     	 

Military Status:

     Branch of Service  __________________  From:  _______________  To:  __________________

     Date of Final Discharge:  _________________________      Reservist:  _______ Yes  _______ No 

     Veteran:   _______ W.W.II    _______ Korea    _______ Vietnam    _______ Mid East

Disability:

  _____  Physical			_____  Vision  			_____  Mental		 

  _____  Hearing			_____  Speech		               _____  Other

Education:

     _____ 1.  Non High School Graduate                                _____ 6.  Post Graduate

     _____ 2.  GED                                                                    _____ 7.  Master
 
     _____ 3.  High School Graduate                                        _____ 8.  Ph.D.

     _____ 4.  Some College _____ yrs.                                   _____ 9. Trade School

     _____ 5.  College Graduate

Employee Signature:  _____________________________      Date:  _____/_____/_____