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GREATER LOS ANGELES AGENCY ON DEAFNESS, INC. VOLUNTARY EMPLOYMENT QUESTIONNAIRE

Applicant: This completed section is confidential and will be detached from your application. This information is voluntary and is gathered in accordance with State and Federal laws for the purpose of evaluating the effectiveness of our equal opportunity and recruitment efforts.

______________________________________________________________________

NAME (Optional) Job Title CHECK ONE:  Male  Female PLEASE CHECK ONE BOX ONLY FOR THE RACIAL/ETHNIC CATEGORY WITH WHICH YOU MOST CLOSELY IDENTIFY WITH (SEE BELOW FOR THE ETHNIC DEFINITIONS)

WHITE

(Not Hispanic Origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

BLACK

(Not Hispanic Origin) All persons having origins in any of the Black racial groups of Africa.

HISPANIC

All persons of Mexican, Puerto Rican, Cuban, or any other Spanish Hispanic (does not include persons of Portuguese or Brazilian origin or persons who acquire a Spanish surname).

ASIAN OR PACIFIC ISLANDER

All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands (excluding the Philippine islands). These areas include for example, China, Japan, Korea, and Samoa.

AMERICAN INDIAN OR ALASKAN NATIVE

All persons having origins in any of the original peoples of North America, or/and who maintain cultural identifications through tribal affiliation or community recognition. PLEASE IDENTIFY YOUR TRIBAL AFFILIATION:  

FILIPINO

All persons having origins in the Philippine islands.

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