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Applicant DATA FORM

APPLICANT INFORMATION

 

Affirmative Action Statement

 

Where underutilization exists, the University is committed to taking affirmative action in employment for American Indians/Alaska Natives, Asians, Native Hawaiians and other Pacific Islanders, Blacks, Hispanics, women, and persons age 40 and over. It is also committed to employ and advance in employment, qualified persons with disabilities, qualified disabled veterans, and Vietnam era veterans in all levels of employment.

 

 

The following information is needed for evaluation of recruitment programs, monitoring, and reporting only according to Executive Order 11246, and the State of Florida nondiscrimination regulations. Your response is voluntary. Refusal to respond will not subject you to adverse treatment in employment consideration.

 

 

  ______________________________________________________________________

 Name of Applicant                                                               

 

 

Race:

      Black or African American                Asian/Pacific Islander

      White                                                  Hispanic

      American Indian or Alaska Native

 

Sex:

        Male

       Female

 

US Veteran Status:

        Disabled Veteran

        Vietnam Era

        Other Eligible Veteran

DEPARTMENT INFORMATION

Department/College (where position is located)

 

 

Position Information:

 

Title:___________________________________________________________________________

Position #:_____________________________or  Tracking #:______________________________

 

How did you become aware of the position_____________________________________________

If it is through newspaper(s)/periodical(s)/other media, please give the name:

________________________________________________________________________________

________________________________________________________________________________

 

 

Equal Opportunity Statement

 

The University of South Florida reaffirms its policy of equal opportunity regardless of race, color, creed, religion, national origin, sex, age, martial status, disability, or status as a disabled veteran or Vietnam era veteran. This policy applies to all programs and facilities including, but not limited to, admissions, educational programs, employment, and patient and hospital services. Any discriminatory action can be a cause for disciplinary action. Discrimination is prohibited by Executive Order 11246 as amended, Title VI and VII of the Civil Rights Act of 1964, Title IX, Sections 503 and 504 of the Rehabilitation Act of 1973, Americans with Disabilities Act of 1990, Vietnam Era Veterans’s Readjustment Assistance Act of 1972 as amended, other federal and state statutes, regulations, and University policy.

 

If you wish to request a disability accommodation during the application process, please contact the hiring department.

 

revised 04/03

 

Return the completed form to the Department named above

 

For your information, the following definitions apply:

 

 

 

 

Black or African American:  means a person with origins in any of the Black racial groups of Africa.

 

Asian: means a person with origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Island, Thailand and Vietnam.

 

 

White: means a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

 

 

Hispanic or Latino or Spanish Origin: means a person with origins of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish Culture or origin, regardless of race.

 

American Indian or Alaska Native: means a person with origins in any of the original peoples of North America and South America (including Central America) and who maintains tribal affiliation or has community recognitions as an American Indian or Alaska Native.

 

 

Native Hawaiian or Other Pacific Islander: (race) means a person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. (Native Hawaiian does not include individuals who are native to the state of Hawaii by virtue of being born there.)

 

 

Male:  a male applicant.

 

Female: a female applicant.

 

 

Disabled Veteran:  An applicant entitled to disability compensation under Veterans Administration for a disability rate of 30% or more, or whose discharge/release from active duty was for a disability incurred or aggravated in the line of duty.

 

Vietnam Era Veteran: An applicant who: (a) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred (i) in the Republic of Vietnam between February 28, 1961 and May 7, 1975 or (ii) between August 5, 1964 and May 7, 1975, in all other cases; (b) was discharged or released from active duty for a service-connected disability if any part of such activity was performed during the times and places specified under (a).

 

Other Eligible Veteran:  Served on active duty during war or in a campaign or expedition for which a campaign badge has been authorized.

 

 

revised 04/03  (reverse)