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785-8541

READ ONLY!

This document is provided as a courtesy to demonstrate how the
Equal Employment Opportunity Information Request looks.
This online sample is not an official form and cannot be printed and distributed.

PLEASE CONTACT AFFIRMATIVE ACTION & DIVERSITY
TO OBTAIN THIS FORM AT (608) 785-8541

University of Wisconsin - La Crosse

Affirmative Action & Diversity Office

1725 State Street

La Crosse, Wisconsin 54601

(608) 785-8541

EQUAL EMPLOYMENT OPPORTUNITY (EEO) INFORMATION REQUEST

RACIAL/ETHNIC BACKGROUND q Black (not Hispanic): Origins in any of the black racial groups. q Asian or Pacific Islanders Origins in the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. q American Indian or Alaskan Native Origins in the original peoples of North America. q Hispanic: Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. q White (not Hispanic): Originis in Europe, North Africa, or the Middle East. SEX q Female q Male AGE q Under 40 q 40 or over

CITIZENSHIP q U.S. Citizen q Resident Foreign National An alien who has been admitted for permanent residence (must have Alien Registration Card, Form 1-151). q Non-Resident Foreign National An alien admitted temporarily for specific purposes and periods of time. HANDICAP/DISABILITY Any person who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, or (2) has a record of such impairment, or (3) is regarded as having such an impairment. q Yes q No

FOR VETERANS ONLY q Vietnam Era Veteran A person who (a) served on active duty for a period of more than 180 days, any part of which occurred during the Vietnam era (8-5-64 to 5-7-75), and was discharged or released with other than dishonorable discharge, or (b) was discharged or released from active duty for a service connected disability if any part of such active duty was performed during the Vietnam era. q Disabled Veteran A person entitled to disability compensation under laws administered by the Veterans Administration for a disability rated at 30 percentum or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

How did you learn about this vacancy?

q University Posting q Newspaper (Specify )

q Personal Contact q Chronicle of Higher Education

q E-mail/Internet Posting q Professional Journal, Bulletin, or Newsletter

q Other