Date Received: _________________

Please submit this completed form with your application form. The information will be used solely for Equal Employment Opportunity (EEO) purposes in compliance with State and Federal laws and guidelines.

Name: ______________________________ Soc. Sec. #: _______________________

Classification/Job for which you are applying: _________________________________

How did you learn about this position? _______________________________________

________ Male _________ Female

Birthdate: ____________________

Please Check:

A)	__________	White	Persons having origin in any of the original people of Europe, North Africa or Middle East.
B)	_________	Black	Persons having origin in any of the Black racial groups
C)	__________	Hispanic	Persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origins regardless of race.
D)	__________	American Indian or Alaskan Native	Persons having origins in any of the original people of North America and who maintain cultural identification through tribal affiliation or community recognition.
E)	__________	Asian/Pacific Islanders	Persons having origins in any of the original peoples of the Far East, Southeast Asia, Indian Subcontinent, or the Pacific Islands.
F)	__________	Handicapped	Individual with a physical condition that limits his/her ability to attain employment.

Date of first interview: ___________________ Date of second interview: ____________________

Was a job offer made to this applicant? _____Yes _____ No

If yes, did they accept the job? _____Yes _____No If yes, date of hire: ____________________

If no to either question, list why: ____________________________________________________

_______________________________________________________________________________

Name of interviewer(s): ________________________________

Name of person making employment decision: ______________________________

SPECIAL NOTE: The applicant flow record will be kept separate from the applicants resume or application.