EMPLOYEE VOLUNTARY SELF-IDENTIFICATION SURVEY

The Company is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, sex, age, national origin, disability or veteran status. In compliance with our obligation to complete the government-required EEO-1 Report, we invite you to voluntarily self-identify your sex, ethnicity and/or race below. Completion of this data is voluntary and will not affect the terms or conditions of employment. This data will be kept in a confidential file.

NAME: _______________________________________________________ DATE: ______ - ______ - 2_____

POSITION : ______________________________________________________________________________

1. SEX: Male______ Female______

2. ETHNICITY: Please check below if you are Hispanic or Latino. If you are not, skip this question and go to question #3.

_______ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

3. RACE: Please check your race or races below. If you have answered questions #2, do not answer #3.

________ White (not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

________ Black or 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.

________ 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 or 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 tribal affiliation or community attachment.

________ Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above five races.

Shared: forms_acknowledgements: employee voluntary self ID survey 778681.1