MANDATORY
2 PROOFS OF
ID NEEDED
EMPLOYMENT DATASHEET
__________________
__________________ _________________
____________
Last
Name
First
Name
Middle
Date
________________________________________
_________________________
Address
Phone
___________________________
__________
____________ ______________
City
State
Zip
Date of Birth
_________________________
____________________________ ____________
Social Security
Number
License
Number
Expire Date
EEO DATA
Title VII of the Civil Rights Act requires us to report to the Equal Opportunity Commission (EEOC) the composition of our work force with respect to racial/ethnic origin and sex. We must also comply with the Age Discrimination Act. To aid us in accumulating this data, please complete this section. It will not be available to any supervisory employee who may be considering any action concerning your employment, discharge, compensation, or terms, conditions or privileges of employment. I understand and agree that if I am ever subjected to any form of discrimination including sexual harassment, I will immediately contact my employer to resolve the matter.
EEOC Category of Racial/Ethnic
Origin
SEX: Male
Female
______ White (Not of Hispanic Origin)
______ Black (Not of Hispanic
Origin)
VETERAN STATUS:
______
Hispanic
_______ Veteran
______ Asian of Pacific
Islander
_______ Non-Veteran
______ American Indian or Alaskan
Native _______
Vietnam Veteran
_______________________________________
SIGNATURE