State of Washington
Department of Personnel
APPLICANT PROFILE DATA FORM

Completing this form will enable Washington State to assess the many talents and skills that are available throughout the workforce. To ensure equal employment opportunity, we ask your voluntary cooperation in responding to the questions below. This information will be treated as confidential, and will be available only to authorized personnel. Please review the Affirmative Action Definitions below.

1. What race or culture do you consider yourself? If you are more than one race, please check "Other Race."

Other Race (specify/indicate race or culture):

If you are more than one race, also check "Multi-Racial" and indicate your preference for Affirmative Action purposes:
Multi-Racial:

2. Are you? Male     Female
3. Have you ever been on active duty in the U.S. Armed Services? Yes (if checked, see 3a and 3b) No
    3a. Dates served: from: to     3b. Are you a disabled veteran? Yes (%)   No
4. Do you have any physical, sensory, or mental condition that substantially (rather than slightly) limits any of your major life functions, such as: walking, speaking, seeing, hearing, breathing, working, learning, caring for oneself or performing manual tasks?Yes  No

American Indian or Alaskan Native. A person with origins in any of the original peoples of North America and who maintains cultural identification through documented tribal affiliation or community recognition.

Asian/Pacific Islander. A person with origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. For example, China, Japan, Korea, Pakistan, the Philippine Republic, and Samoa.

Black/African-American. A person with origins in any of the Black racial groups of Africa.

Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race. For example, persons from Brazil, Guyana, or Surinam would be classified according to their race and would not necessarily be included in the Hispanic category. This category does not include persons from Portugal, who should be classified according to race.

White/Caucasian. A person with origins in any of the original peoples of Europe, North Africa, or the Middle East.

Disabilities. For Affirmative Action purposes, people with disabilities are persons with a permanent physical, mental, or sensory impairment which substantially limits one or more major life activities. Physical, mental, or sensory impairment means: (a) any physiological or neurological disorders such as mental functions; or (b) any mental or psychological disorders such as mental retardation, organic brain syndrome, emotional or mental illness, or any specific learning disability. The impairment must be material rather than slight, and permanent in that it is seldom fully corrected by medical replacement, therapy, or surgical means.

Disabled veteran. A person entitled to disability compensation under laws administered by the U.S. Department of Veteran Affairs for disability rated at 30 percent or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

Vietnam-era veteran. A person who 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 from duty with other than a dishonorable discharge.

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