Affirmative Action
Data Collection Form

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As an Equal Opportunity/Affirmative Action Employer and in compliance with federal directives pursuant to Executive Order 11246 (as amended by EO 11357), State University of New York at Fredonia is required to maintain records of sex, ethnic background, disability and veteran status of all applications for employment. The form below should be completed and submitted by all applicants. It will not be placed in your application file. We appreciate your cooperation.

Name_________________________________________________________
Last First M.I.

Position Applied For______________________________________________ Department Title

Source________________________________________________________ (How did you find out about the position?)

Check all that apply

Female______Male______Vietnam Era Veteran______

Do you wish to identify a disability? __________________________________

Ethnic Category: (Please Check One)

______White, not of Hispanic Origin - origins in any of the original people in
Europe, North Africa or the Middle East

______Black, not of Hispanic Origin - origins in any of the original peoples of
Africa

______Hispanic - origins of Mexican, Puerto Rican, Cuban, Central or South
American or other Spanish culture, regardless of race

______Asian or Pacific Islander - origins in any of the original people of the Far
East, SE Asia, the Indian Subcontinent, or Pacific Islands

______American Indian or Alaskan Native - origins in any of the original people of
North America who maintain cultural identification through tribal affiliation
or community recognition

Please Tape and Seal