Everett Public Schools

EVERETT PUBLIC SCHOOLS

Human Resources

3715 Oakes Avenue

Everett, WA 98201

APPLICANT OPTIONAL DATA

Everett Public Schools is an Equal Opportunity Employer. In completing the following data you will assist us in monitoring our Equal Employment Opportunity effectiveness. The following information is STRICTLY VOLUNTARY and will not be part of your application for employment. Any information provided will be kept confidential. If you choose not to answer any of these questions, you will not be subject to any adverse treatment.

Name______Date______

Position Applied for______

Are you over 40 years of age? ___Yes ___ No Sex: ___ Male ___ Female

I consider myself to be disabled: ___ Yes ___ No

If yes, please explain______

(Federal regulations define a disabled person as one who (1) has a physical or mental impairment which substantially limits one or more of such person's major life activities, (2) has a history of such impairment, or (3) is regarded as having such an impairment.)

I consider myself to be a member of the following ethnic group:

Asian or Pacific Island
American / Chinese, Japanese, Korean, Hawaiian, Samoan, or Filipino and
Peoples of the Far East and Southeast Asia
Black American / Black or African American descent
American Indian / Native American Indian descent, including Canadian and Alaskan
Natives
Hispanic American / All persons of Mexican, Puerto Rican, Cuban, Central or South
American or other Spanish culture or origin
Caucasian / White American
Other (Please Specify)

Disabled and Vietnam-Era Veteran Affirmative Action Program

A.  Vietnam-Era veteran: The term "Veteran of the Vietnam Era" means a person who (1) served on active duty for a Period of more than 180 days, any part of which occurred during August 5, 1964 through May 7, 1975 and was discharged or released therefrom with other than a dishonorable discharge, or (2) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed during the Vietnam Era.

B.  Disabled Veteran: The term "disabled veteran" means a person entitled to disability compensation under laws administered by the Veterans' Administration for a disability rated at 30 percent or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

(II) I meet the definition for "Disabled Veteran." ___ Yes ___ No

Signature:______Date:______ HR/Rev: 9/19/03