Voluntary Self-Identification – Gender Ethnicity Race

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VOLUNTARY SELF‐IDENTIFICATION FORM 1 – RACE/GENDER (GENDER, ETHNICITY AND RACE SELF‐IDENTIFICATION)

GCR, Inc. is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, GCR, Inc. invites applicants to voluntarily self‐identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not affect the decision regarding your application for employment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

If you choose not to self‐identify at this time, the federal government allows this employer to determine the information asked below by visual survey.

What is your gender? Check only ONE box:

Are you Hispanic or Latino? (A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

Indicate by checking only one of the following EEOC classifications. The EEOC requires that we report only one race/ethnic origin for each person. If you indicated that your ethnicity is Hispanic or Latino, do not check a category below.

Name:

Date:

Signature