Equal Employment Opportunity (EEO)
Self-Identification Form
Nextran Corporation is an equal opportunity employer committed to providing a working environment where all qualified individuals are considered for employment without regard to race, color, national origin, religion, gender, age, disability, or veteran’s status. To fulfill our EEO-1 reporting obligations, we request your voluntary completion of the information below. Please be assured that you will not be subjected to any adverse treatment if you do not provide the information requested. If you do not self- identify, identification will be made visually pursuant to EEO-1 reporting requirements. The information collected will be kept confidential and will only be used to report in summary fashion for compliance purposes. When reported, data will not identify any specific individual. The information and this form will be processed and maintained separately from your employment application forms and your personnel file.
Check one:
____ Male____ Female____ I do not wish to provide this information
Please also check one of the following:
Race/Ethnic Group:
For the purpose of this form, please indicate the group in which you appear to belong, identify with, or regarded in the community as belonging. However, only count yourself in one ethnic/minority group.
____ Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
____ White (not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
____ Black or African American (not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
____ Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other PacificIslands.
____ Asian (not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
____ American Indian or Alaskan Native (not Hispanic or Latino) – A person having origins in any of the peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
____Two or More Races (not Hispanic or Latino) – A person falling into one or more of the five categories above, excluding Hispanic or Latino.
____ I do not wish to provide this information
Name:______Last 4 Digits of SSN:______Last First Middle
Signature: ______Date: ______