Southern States Employment Application

Form HR-5H - Rev. 3/07

Application Information (Completion of this section is required.)

Name:

Last

First

Middle

Suffix

Present Address:	Street and/or P.O. Box
	City	State	Zip Code
Email Address:

Phone Info: (XXX)-XXX-XXXX	()- Home:	()- Mobile:

Position applied for:	Instructional Designer (Contract)
Date Inserted:	10/28/2009
Salary requirement:
Location:	Corporate Headquarters, Richmond, VA

Resume - You can paste your resume in from Microsoft Word (please be sure to use the Paste From Word button), or use the formatting toolbar.

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.

I Decline. I prefer not to provide this information. (No Affirmative Action Voluntary Information will be submitted.)

Gender: MaleFemale

Equal Opportunity Identification Groups:

African_American/BlackNative Hawaiian/Other Pacific Islander
American Indian/Alaskan NativeTwo or more races
AsianWhite
Hispanic/LatinoOther