Luther Burbank School District
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Luther Burbank School DistrictEmployee/Applicant Identification Form Section 1233 of the California Government Code permits School districts to solicit from employees a VOLUNTARY declaration of their sex and racial group membership. Information provided will assist the district in accurately compiling required statistical reports for federal and state agencies. A separate, confidential file will be established for these forms and none of the information will be used to discriminate against or give preference to any individual in any personnel transaction. ___________________________________________________________________________________ Desired Position:________________________________________________ Full time / Part Time Male / Female (Circle one) (Circle one) ___________________________________________________________________________________
best identifies your racial/ethnic background. B lack (Negro, Afro-American, African Filipino (Filipino-An~erican and descent, Trindadian, Jamaican, West Indian) Filipino descent)
sian (Asian-American, Japanese, Chinese or Native American (American Indian) Korean descent)
Rican, Latin American or Spanish descent) other nonwhite not specified above)
White (White, Anglo, Pakistani, East DECLINE TO STATE Indian, Indo-European descent)
If you are physically handicapped check all applicable categories. ____ Hearing (50% or more loss of hearing in both ears) ____ Speech ____ Sight (use of eyeglasses does not apply) ____ Impairment (Due to amputation, loss of functions, loss of coordination) ____ Other (please specify) Directory: cms -> lib07 lib07 -> Find fantastic ousd elementary music programs lib07 -> TrackingHurricane Katrina Introduction lib07 -> Shriya Arya, Ria Bhatia, Anna Chen, Saloni Jain, and Anna Chen lib07 -> How was the economy after wwii? lib07 -> Unit 10: Modern ga and Civil Rights I. Post-World War II georgia Agriculture lib07 -> Mandarin high school lib07 -> Name: Date: Period: Tracking Hurricane Sandy Intro lib07 -> Eastern suffolk boces school library system lib07 -> School Health Advisory Council (shac) Meeting September 17 Download 7.59 Kb. Share with your friends:
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