AFFIRMATIVE ACTION PLAN

VOLUNTARY SELF-IDENTIFICATION

__________________________________________ _________/_________/_________
Name (Last, Middle, First) Application Date: MM/DD/YY

Office/Location Where Applied: (Please include City and State) _____________________________

Position Applied For (Be Specific): ______________________________________________________

Completion of this survey is voluntary and will be used for Federal Reports (VETS-100 and EEO-1) to assist the
Department of Labor in determining whether protected veterans, minorities, and females benefit from affirmative
action in obtaining and advancing in employment. Disclosing or not disclosing information will not subject any
applicant or employee to adverse treatment. The information you furnish will be maintained only for the purpose of
monitoring compliance with applicable laws and regulations concerning equal employment opportunity and will not be
used for any other purpose.

Please check all that apply to you:

______ DISABLED VETERAN
(i) A veteran who is entitled to compensation (or who, but for receipt of military retired
pay, would be entitled to compensation) under laws administered by the Secretary of
Defense for a disability, or
(ii) A person who was discharged or released from active duty because of a service-
connected disability.

______ RECENTLY SEPARATED VETERAN

Any veteran during the three-year period beginning on the date of such veterans discharge
or release from active duty.

______ ARMED FORCES SERVICE MEDAL VETERAN

A person who, while serving on active duty in the Armed Forces, participated in a United
States military operation for which an Armed Forces service medal was awarded pursuant to
Executive Order 12986 (62 FR 1209).

______ ACTIVE DUTY WARTIME OR CAMPAIGN BADGE VETERAN

A person who served on active duty during a war or in a campaign or expedition for which a
campaign badge has been authorized, under laws administered by the Department of Defense
(ex. Vietnam, Persian Gulf, Kosovo, Iraq, Afghanistan).

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse
treatment. If you choose not to, your identification will be made by visual observation.

Indicate Gender and Race/Ethnic Group:

Check one: ______ Male ______ Female

Check one: ______ Hispanic or Latino

______ White (not Hispanic or Latino)
______ Black or African American (not Hispanic or Latino)
______ Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
______ Asian (not Hispanic or Latino)
______ American Indian or Alaska Native (not Hispanic or Latino)
______ Two or more races

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