directions for filling out the automated job application form

EQUAL EMPLOYMENT OPPORTUNITY
The Kitsap Public Health District is an Equal Opportunity Employer. To help us comply with record keeping, reporting,
and other legal requirements, please complete the survey section below. Providing this information is optional and
entirely voluntary. This information will be kept in a confidential file separate from the application form and will not be
used in the evaluation of your application.
Applicant name:
Job title applied for:
Sex: Male Female
Age 40 or over? Yes No
Race: Please check the appropriate designation. You may only check one designation.
White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
Black/African American (Not Hispanic or Latino): A person having origins in any of the black racial
groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of
the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Hispanic/Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin regardless of race.
Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including for example Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian/Alaska Native (Not Hispanic or Latino): A person having origins in any of the original
peoples of North and South American (including Central America), and who maintain a tribal affiliation
or community attachment.
Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the
above races, excluding those who identify themselves as Hispanic or Latino
Disability: A person has a disability if he or she has a sensory, mental, or physical impairment that is medically
cognizable or diagnosable; the impairment must have a substantially limiting effect upon the person’s ability to
perform his or her job, the person’s ability to apply or be considered for a job, or the person’s access to equal benefits,
privileges, or terms or conditions of employment.
Do you meet this definition? Yes No
How did you learn of this employment opportunity? Please indicate specific publication(s) or Website(s) if
applicable.
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