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ADDITIONAL INFORMATION

NOTE: COMPLETION OF THIS FORM BY APPLICANT IS STRICTLY VOLUNTARY AND WILL BE FILED SEPARATELY FROM APPLICATION
We consider all applications without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disability, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws, governing employment practices and do not discriminate on the basis of any unlawful criteria.
In an effort to obtain accurate community representation and to comply with requirements regarding government record keeping, reporting and other legal obligations that may apply, we require that you complete the applicant data survey. Failure to provide information will not subject you to any adverse personnel decision or action and your cooperation is appreciated.
Gender
1. Male
2. Female
Race
1. White (not of Hispanic origin)
2. Black (not of Hispanic origin)
3. Hispanic
1. Asian or Pacific Islander
2. American Indian or Alaskan Native
Physical
Do you have a physical, sensory, or mental impairment that substantially limits one or more life activities (i.e. walking, seeing, hearing, learning and/or breathing)?
1. Yes
2. No
Are you a Veteran
1. Yes
2. No
Are you a Disable Veteran?
Definition: (i) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who, but for the receipt of military retired pay, would be entitled to compensation) under laws administered by the Secretary of Veterans Affiars, or (ii) A person who was discharged or released from active duty because of a service-connected disability.
1. Yes
2. No
Are you a Vietnam Era Veteran?
Definition: A person who (i) served on active duty in the U.S. military, ground, naval, or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or (B) between August 5, 1964 and May 7, 1975, in all other cases; OR (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service-connected disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (B) between August 5, 1964 and May 7, 1975 in any other location.
1. Yes
2. No
Political Affiliation
State laws require information about political affiliation for some boards and commissions. Please check the following as it applies to you.
1. Democrat
2. Republican
Indicate the last Primary Election voted in and party affiliation declared in that election:
Electronic Signature*
By checking "I Agree" you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
1. I Agree

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