EQUAL OPPORTUNITY/AFFIRMATIVE ACTION
                                               INFORMATION REQUEST

Since you have recently applied for a position at the University of Massachusetts Amherst, we would appreciate your cooperation in providing the information requested on this form.  Your participation is voluntary, and will in no way affect your eligibility for employment. This information is confidential and will be used to determine the success of the University's affirmative action outreach programs and to comply with federal and state law.

Please return this form to the University Department conducting the search (see address on enclosed letter).

NAME: ___________________________________________________   DATE: ___________________________________________

POSITION APPLIED FOR: _________________________________________   RANK: ________________________________

DEPARTMENT/SCHOOL: ____________________________________________________________________________________

Information on this position came to me from the following source: (Name specific newspaper, journal, person, etc.)

_______________________________________________________________________________________________________________

ETHNIC DATA:

The categories below should not be interpreted as scientific or anthropological in nature.  They were developed

by the Federal government to provide for the collection and use of compatible and exchangeable ethnic data by

Federal agencies: (CHECK ONE)

  _____          White (a person not of Hispanic origin, having origins in any of the original peoples of Europe, North Africa, or the Middle East.)

  _____          American Indian or Alaska Native (a person having origins in any of the original peoples of North America and who maintains a cultural identification through tribal affiliation or community recognition.)

  _____          Asian or Pacific Islander (a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.)

  _____          Black/African American (a person not of Hispanic origin, having origins in any of the Black racial groups of Africa.)

  _____          Cape Verdean (a person not of Hispanic origin, having origins in any of the peoples of the Cape Verde Islands.)

  _____          Hispanic/Latino (a person of Mexican, Puerto Rican, Cuban, Central American, South American or other Spanish culture or origin, regardless of race.)

SEX:   FEMALE ________    MALE _______

VETERAN STATUS:

VIETNAM ERA VETERAN?   ______ YES   _______ NO

OTHER VETERAN?                 ______ YES   _______ NO

See Military Status definitions on the reverse side.

MILITARY STATUS DEFINITIONS

VETERAN OF THE VIETNAM ERA:

A Veteran of the Vietnam era is a person who:

(A) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred:  (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964, and May 7, 1975, in all other cases; or

(B) was discharged or released from active duty for a service connected disability if any part of such active duty was performed:  (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964, and May 7, 1975, in all other cases.

OTHER VETERAN:

Any other Veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

In compliance with Federal Regulations and the Jeanne Clery Disclosure of Campus Crime Statistics Act, a copy of the University of Massachusetts Amherst Annual Security Report is available online at www.umass.edu/umpd/pdffiles/ASR.pdf  A hard copy of the report may be obtained by contacting the UMass Amherst Police Department at (413) 545-2125.  This report includes crime statistics for the previous three years as well as institutional policies concerning campus security.

EO&D 7/08