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APPLICANT DATA RECORD <br />The City of Centerville is an Equal Opportunity Employer in its recruitment and procedures. Applicants are <br />considered for all positions, and employees are treated during employment without regard to race, color, <br />religion, sex, national origin, age, marital or veteran status, medical condition or handicap. <br />As an employer/government contractor, we comply with government regulations and affirmative action <br />responsibilities. <br />Solely to help us comply with State and Federal record keeping, reporting and other legal requirements, <br />please complete the Applicant Data Record. Periodic reports are made to the government using the following <br />information. This form will be filed separate from your application and it will not be used in our recruitment <br />evaluation process. The following information is requested for reporting purposes only. Please note that your <br />cooperation in providing the following data is voluntaryand inclusion or exclusion of data will not affect <br />any recruitment selection decisions. We appreciate your cooperation. Refusal to provide this information will <br />not disqualify you from present or future employment or adverse treatment. <br />Title of Position Applying For: Today’s Date <br />Sex: ______Female ______Male <br />Date of Birth ________/________/________ Age: _______ <br />(mo/day/yr): <br />Please check one of the following: <br />____White (non-Hispanic) ____Black or African American ____Hispanic or Latino ____Asian or Pacific Islander <br />____American Indian or Alaskan Native ____Other <br />Please check if any of the following are applicable: <br />____Disabled Individual ____Veteran ____Disabled Veteran ____Spouse of Disabled or ____Deceased Veteran <br />REFERRAL SOURCE <br />How were you made aware of this employment opportunity? <br />___Internet (specify site):___________________________________________________________________________________ <br />___Newspaper (Specify paper):______________________________________________________________________________ <br />___Employment Agency (List name):_________________________________________________________________________ <br />___Employee Referral (Provide name):________________________________________________________________________ <br />___Community Agency Referral (specify name):________________________________________________________________ <br />___Walk-In <br />___City of Blaine Job Line <br />___Other Source:_________________________________________________________________________________________ <br />THIS FORM WILL BE SEPARATED FROM YOUR APPLICATION FORM. <br /> <br />