Applicant Demographics Form

Position:*

First Name:*

Last Name:*

Middle Name:

Home Address:

Home Phone:

Email:

Gender:*

Gender:Male Female

Ethnic Group:*

Special Employment Notice for the Disabled

A disabled person is one who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having one. If hired, a supervisor may be informed of restrictions on duties and informed of necessary accommodations. Safety personnel may be informed as well as government officials investigating compliance, if necessary.

A disabled applicant or employee may request reasonable accommodation in order to perform the essential job functions, and the city will provide reasonable accommodation for that purpose unless undue hardship would result.

Disabled

Veterans

Disabled Veteran

Vietnam Era Veteran

Veteran (other)

Age range*

Age rangeunder 16 16-17 18-39 40 and over

Voluntary Cooperation

This information will be kept separate from your employment application and is considered confidential. Refusal to provide this information will not subject you to adverse treatment.

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Applicant Demographics Form

Human Resources Office