Southern States Employment Application

Form HR-5H - Rev. 3/07
Application Information (Completion of this section is required.)
Name:

Suffix

Middle

First

Last
Present Address:

Street and/or P.O. Box

City

Zip Code

State

Email Address:


Position applied for:
Date:
Location:
Upload your resume here:
Affirmative Action Voluntary Information (Completion of the following information by the applicant is voluntary. It is not for interview purposes and will be filed separately from application.)

We consider contractor applicants without regard to age, race, color, sex, religion, national origin, disability, veteran status or any other protected status.

As required, we comply with government regulations including Affirmative Action obligations where they apply. In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that this survey is not part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

1. Please Check one in each of the following categories (or see item 2 below)
Gender:
Male
Female
Equal Opportunity Identification Groups:
African_American/Black
American Indian/Alaskan Native
Asian
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
Two or more races
White
Other
Referral Source:
Newspaper

(List Publication)
Career Fair
Internet

(List Web Site)
Employee

(List Name)
Walk-in
Other
Educational Institution
2.
Decline. I prefer not to provide this information.