City of Monroe ____________________________________________________

The City of Monroe is an Equal Opportunity Employer (EOE). The following information is used to monitor this goal. This information will be kept separate from your application and kept confidential in accordance with applicable laws and regulations. This information will not beused to make employment decisions. Completion of this form is strictly voluntary and you do not have to answer any question you believe to be discriminatory.

Affirmative Action Data Form Equal Opportunity Employer

Date:______________________ Male Female

Name:_______________________________________________________________________

Address:_____________________________________________________________________Street City State Zip

Please check one of the following Equal Employment Opportunity Identification Groups: American Indian/Alaskan Native: Persons having origins in any of the original peoples ofNorth American, and who maintain cultural identification through tribal affiliation or communityrecognition.

Asian/Pacific Islander: Persons having origins in the Far East, Southeast Asia, the Indiansub-continent, or Pacific Islands. These areas include China, Japan, Korea, the PhilippineIslands, Samoa, India, Pakistan, Bangladesh, Sri Lanka, Sikkim, and Bhutan.

Black: A person who is not of Hispanic origin, but having origins in any of the Black racialgroups of Africa.

Caucasian: A person who is not of Hispanic origin, but having origins in any of the originalpeoples of Europe, North Africa, or the Middle East.

Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central American, South American,or other Spanish culture or origin, regardless of race.

Other: Please specify ______________________________________________________.

How did you learn of this position vacancy (check all that applies)?

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