Voluntary Information Form

Human Resources

Lewis & Clark is committed to monitoring our recruitment and selection process in order to assure equal opportunity. We would appreciate your cooperation in providing the following information. Your cooperation is voluntary. The information is for statistical use only and will be kept confidential and separate from your application for a faculty appointment. If you have any questions, please contact the Human Resources at 503-768-7835.

First Name:

Middle Initial:

Last Name:

Social Security Number: Optional

Date of Birth:

Gender:

Female Male

Specific Position Applied For:

Disabled: Person who (a) has a physical, mental or sensory impairment which substantially limits one or more of such person's major life activities, (b) has a record of such an impairment or (c) is regarded as having such an impairment. Are you disabled?
Yes No

Disabled Veteran: Person entitled to disability compensation under laws administered by the Veterans' Administration for disability rated at 30 per centum or more, or persons whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty. Are you a disabled veteran?
Yes No

Veteran of the Vietnam Era: Person (1) who (i) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964, and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge, or (ii) was discharged or released from active duty for a service-connected disability if any part of such duty was performed between August 5, 1964, and May 7, 1975, and(2) who was so discharged or released within 48 months preceding his/her application for employment. According to the above definition, are you a Veteran of the Vietnam Era?
Yes No

Check the recruitment source which prompted you to apply:

Professional Publication Please indicate which:	Newspaper Ad Please indicate which:
Referred/Nominated by Colleague	College/University Placement Office
Professional Placement Service	Other:

Race/Ethnic Identification:

White, not of Hispanic Origin (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East)

African or African American, not of Hispanic Origin (Persons having origins in any of the Black racial groups of Africa)

Hispanic or Hispanic American, (Persons of Mexican, Puerto Rican, Central or South American or other Spanish culture or origin, regardless of race)

Native American, or Alaskan Native, (Persons having origins in any of the original peoples of North America, and who maintain cultural identification through affiliation or community recognition)

Asian or Asian American, (Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands)

Contact Us

The Office of Human Resources is located in South Chapel Annex.

email hr@lclark.edu

voice 503-768-6235
fax 503-768-6233

Director Isaac Dixon

Office of Human Resources
0615 S.W. Palatine Hill Road, MSC 72
Portland, Oregon 97219