University of Massachusetts Amherst
Since you have recently applied for a position at the
Please return this form to the University Department conducting the search (see address on enclosed letter).
NAME: ___________________________________________________ DATE: ___________________________________________
POSITION APPLIED FOR: _________________________________________ RANK: ________________________________
Information on this position came to me from the following source: (Name specific newspaper, journal, person, etc.)
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
_____ 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
_____ 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 _______
OTHER VETERAN? ______ YES _______ NO
See Military Status definitions on the reverse side.
MILITARY STATUS DEFINITIONS
VETERAN OF THE
A Veteran of the
(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.
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.