It is Company X’s policy to afford equal employment opportunity to all individuals, with all employment decisions based upon merit and business needs, and not on race/ethnicity, color, citizenship status, national origin, ancestry, sex, age, religion, creed, physical or mental disability, medical condition, marital status or veteran status.

Applicants are requested, but not required, to complete this form. The data you provide will be used solely for statistical purposes to help us comply with Federal and State equal opportunity record keeping, reporting and other legal requirements. Your voluntary cooperation will be appreciated.

Applicant Name: ________________________________ Date of Application: ___________

Position Applying For: _________________________________________________________

Referral Source: ____________________________ Specific: __________________________