EEO SELF IDENTIFICATION FORM

Equal Employment Opportunity

hrmcorrespondence@co.kane.il.us

Kane County and elected and appointed officials consider applicants for all positions without regarding to race, color, religions, sex, national origin, ancestry, age, order of protection status, marital status, physical or mental disability, military status, sexual orientation, pregnancy, or unfavorable discharge from military service. As required, Kane County and the elected and appointed officials comply with government regulations when they apply.

Please be advised that this survey is not a part of your application for employment. This survey is considered confidential information that will not be used in any hiring decision. This information is used for compiling and analyzing equal employment statistics only. Completion of this form is voluntary.

Positions Applied For
Job Title

Date

Applicant Information
Name Ph

Address

Gender Male Female

Equal Employment Opportunity Group
Race White American Indian/Alaskan Native Black (not of Hispanic Origin) Asian/Pacific Islander Hispanic Two or more races

Individuals with a Disability
Individual with a Disability

Veteran's Status
Veteran Status: Veteran Vietnam-Era Veteran Disabled Veteran Special Disabled Veteran

Referral Source
Walk-in

Relative

Advertisement/Newspaper

County department/office

County employee

School/College

Faith based organization

Other

PLEASE READ THE FOLLOWING BEFORE SIGNING
Kane County is an equal opportunity employer. Auxiliary aids and other reasonable accommodations are available upon request to applicants, employees and other individuals with disabilities and to individuals who are pregnant and in need of reasonable accommodation to effectively participate in the application process.

Click the box, it acts as my signature. I acknowledge that all information contained herein is true and accurate to the best of my knowledge.

Name Other: