Self ID form

Application Self-Identification Form

APSU complies with Titles VI and VII of the Civil Rights Act of 1964, as amended, the Equal Pay Act of 1963, as amended, the Age Discrimination in Employment Act of 1967, as amended, the Age Discrimination Act of 1975, the Pregnancy Discrimination Act, the Rehabilitation Act of 1973, the Vietnam Era Veterans' Readjustment Assistance Act of 1974, Title IX of the Educational Amendments of 1972, and the Americans with Disabilities Act of 1991. SUBMISSION OF INFORMATION REQUESTED ON THIS FORM IS ENTIRELY VOLUNTARY AND REFUSAL TO PROVIDE IT WILL NOT SUBJECT YOU TO ANY ADVERSE TREATMENT. Information obtained concerning individuals will be kept confidential, except as specified in applicable federal rules and regulations.

Date:

Job Title:

Department:

Name:

Federal Law provides for Affirmative Action efforts for minority groups. Please check appropriate blocks. INFORMATION PROVIDED ON THIS FORM IS ENTIRELY VOLUNTARY.

White, not of Hispanic origin: A person having origins in any of the original peoples of Europe, North America or the Middle East.
Black, not of Hispanic origin: A person having origins in any of the Black racial groups of Africa.
Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
Asian or Pacific Islander: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, Japan, the Philippine Islands, and Samoa.
American Indian: A person having origin in any of the original people of North America and who maintains cultural identification through tribal affiliation or community recognition.
Alaskan Native: A person having origins in any of the original Alaskan people.

Sex
Male
Female

Date of Birth:

National Origin (Country of Birth):

Please verify that the name and information selected are correct. Once you click the Submit button below, submission errors that are not the result of a technical problem can not be changed. By selecting "Yes" from the drop down list below, you certify that you have reviewed the information above and would like to continue.