Applicant Name:
Last: First: MI:

Address:

Position Applied For:

Today's Date:

Valparaiso University is an Equal Opportunity Employer and is obligated to comply with applicable government record keeping, reporting and other legal requirements. Periodic reports are made to the government to report certain information. It is a requirement of Valparaiso University to solicit the information indicated below, #1 through #4. Your responses are voluntary and your cooperation in providing the information is appreciated. Inclusion or exclusion of any data will not affect any employment decisions.

Once you enter your information, please mail the form to the Affirmative Action Officer, Office of Human Resource Services, 1700 Chapel Drive, Valparaiso, IN 46383 or fax to 219-464-6887.

SECTION B - GENDER/RACE/ETHNICITY/VETERAN

1. GENDER:    Male     Female
   
2. RACIAL OR ETHNIC DATA
   • Are you Hispanic or Latino?    Yes     No
     (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
   • Are you from one or more of the following races? If YES, select one or more:
     

     	American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America including Central America and who maintains a tribal affiliation or community attachment
     	Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
     	Black or African American : A person having origins in any of the black racial groups of Africa.
     	Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
     	White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

3. VETERAN DATA
   • Do you qualify as a Vietnam Era Veteran?
     Any veteran of the armed services who served on active duty for at least 181 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged honorably or released sooner because of a service-related disability.
     Yes     No
     
   • Are you considered a disabled veteran by the U.S. Veteran’s Administration?
     (Any person entitled to compensation by the Veteran’s Administration for a disability rated at 30% or more, or who was discharged or released from active duty by reason of service-related disability.)
     Yes     No
     
4. DISABILITY DATA
   Do you have a physical or mental disability which substantially limits one or more major life activities?
   Yes     No
   
   If "Yes" please identify the impairment.
   Speech Impairment
   Hearing Impairment
   Motor Impairment
   Visual Impairment
   Multiple Disability
   Mental Disability
   Other: