Self Identification Form For Applicants

Please take a moment to complete the following. Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, status regarding public assistance or other protected classification. This information is voluntary and confidential and is collected only for the purpose of creating and maintaining our records. The following information is not shared with the hiring manager. We appreciate your cooperation.

Sex:*

Race/Ethnicity (Check all that apply):
Other, please specify:

Position Applied For:

Veteran Status:*

Disability Status:*
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral Palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular Dystrophy
  • Bipolar Disorder
  • Major Depression
  • Multiple Sclerosis (MS)
  • Missing Limbs or
    Partially Missing Limbs
  • Post-Traumatic Stress Disorder (PTSD)
  • Obsessive Compulsive Disorder
  • Impairments Requiring the use of a Wheelchair
  • Intellectual Disability (previously called mental retardation)

Please check one of the boxes below:*



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