Affirmative Action Self-Identification Form Employees of Laura Baker Services Association (LBSA) are treated during the hiring process and employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. As an employer with an Affirmative Action Program, LBSA complies with government regulations, including Affirmative Action responsibilities where they apply. The purpose of this Data Record is to comply with government recordkeeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a Confidential File and are not a part of your application for employment or personnel file. Please note: Your cooperation is voluntary. Inclusion or exclusion of any data will not affect any employment decision.Name First Middle Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneReferral SourceAdvertisementEmployeeRelativePrivate Employment AgencyFriendInquiryGovernment Employment AgencyOtherList Other Referral SourceBirthdateGenderMaleFemaleEthnic OriginWhiteBlackHispanicAmerican Indian/Alaskan NativeAsian/Pacific IslanderOtherOther Ethnic OriginCheck if any of the following are applicable: Vietnam Era Veteran Disabled Veteran Disabled Individual PhoneThis field is for validation purposes and should be left unchanged.