Goodwill Industries of Southern New Jersey and Philadelphia

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SU	MO	TU	WE	TH	FR	SA

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Voluntary Self-Identification Form
(For Affirmative Action Plan Purposes you are requested to voluntarily provide the information
requested below. Failure to respond will in no way affect the application process)

Goodwill Industries of Southern New Jersey and Philadelphia is an equal opportunity employer and is subject to certain reporting and affirmative action requirements. Qualified applicants are considered without regard to race, color, ancestry, ethnicity, religion, age, sex, national origin, disability, veteran status, sexual orientation, or any other classification protected by federal, state, or local law.

The information requested below is used by Goodwill Industries of Southern New Jersey and Philadelphia to maintain records required of employers doing business with the federal government. In an effort to comply with such requirement, we invite you to complete this form. Providing this information is strictly voluntary and will not be used as a basis for employment decisions. A refusal to complete this form will not subject you to any adverse treatment. The information provided will be held in the strictest confidence, and will be maintained separately from the application.

Section 1: General Applicant Information

Gender: Male Female

Section 2: Please check one of the following Race/Ethnic Categories

Race or Ethnic Identity

	African-American (NOT Hispanic or Latino)
	Asian (NOT Hispanic or Latino)
	Caucasian (NOT Hispanic or Latino)
	Does not wish to furnish this information
	Hispanic or Latino
	Native American/Alaska Native (NOT Hispanic or Latino)
	Native Hawaiian/Pacific Islander (NOT Hispanic or Latino)
	Two or more races (NOT Hispanic or Latino)
	I do not wish to Self-Identify

Section 3: Please select any applicable Disabilities

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