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                                                  Lee College
                                        Applicant Statistical Data Form
To assist us in complying with federal Equal Employment Opportunity and Affirmative Action regulations, we are
requesting that you complete this form. Providing this information is voluntary; the information collected is confidential
and used solely for reporting purposes in accordance with state/federal laws and regulations. This form will be retained
independent of your application and will in no way affect consideration of your employment application.

NAME:                                                                                       DATE OF BIRTH:
POSITION APPLYING FOR:                                                                               JOB REQ #:

GENDER:      ______ Male       ______ Female                        VETERAN STATUS:            ______ Yes         ______ No

CITIZENSHIP (COUNTRY):

ETHNICITY:
    1. Do you consider yourself to be HISPANIC or LATINO?
        (Defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin
        regardless of race. The term “Spanish origin” may be used in addition to “Hispanic or Latino”.)

        ______ Yes (HISPANIC or LATINO)
        ______ No (NON-HISPANIC or LATINO)
    2. If No (NON-HISPANIC or LATINO), what race (or races) do you consider yourself to be? Please select one or more
       of the following.
        ______ AMERICAN INDIAN or ALASKA NATIVE
                 (Defined as a person having origins in any of the original peoples of North & South America <including Central
                 America>, and who maintains a tribal affiliation or community attachment.)

        ______ ASIAN
                 (Defined as 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.)

        ______ BLACK or AFRICAN AMERICAN
                 (Defined as a person having origins in any of the black racial groups of Africa.)

        ______ NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER
                 (Defined as a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
                  Islands.)

        ______ WHITE
                 (Defined as a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)

        ______ RACE & ETHNICITY UNKNOWN

        ______ If you choose not to self-identify your race or ethnicity, check here.



Continued on page 2.
                                                            Lee College Applicant Statistical Data Form – PAGE 2

How did you hear about this position?
        ______ Lee College Human Resources Staff
        ______ Job Bulletin Board in Human Resources
        ______ Lee College Employee Told Me
        ______ A Family Member or Friend Told Me
        ______ Attended a Job Fair


        ______ Baytown Sun Newspaper
        ______ Houston Chronicle Newspaper
        ______ Chronicle of Higher Education Journal
        ______ OTHER NEWSPAPER, PUBLICATION, OR JOURNAL Please specify: ________________________________

        ______ Lee College Website (www.lee.edu/hr)
        ______ Baytown Sun - Jobs Online (www.baytownsun.com)
        ______ Houston Chronicle - Jobs Online (www.chron.com)
        ______ HigherEdJobs.com
        ______ Chronicle of Higher Education - Jobs Online (www.chronicle.com)
        ______ OTHER WEBSITE Please specify: __________________________________________________________


        ______ The WorkSource
        ______ Manpower
        ______ OTHER EMPLOYMENT AGENCY Please specify: ______________________________________________


        ______ OTHER SOURCE NOT LISTED ABOVE Please specify: ___________________________________________




Please return this form with your application or mail to:    Lee College Human Resources Office
                                                             Attn: Affirmative Action File
                                                             P.O. Box 818
                                                             Baytown, TX 77522-0818

				
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posted:7/25/2009
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