EEO Self-Identification Form

Savoy Medical Center is an equal employment opportunity/affirmative action employer. Certain laws and regulations regarding equal employment opportunity/affirmative action require us to compile annual statistical reports on applicants for employment. In order to comply with these laws and regulations, we are requesting your cooperation in completing this EEO Self-Identification Form. The information on this EEO Self-Identification Form is being requested and will be used solely for equal employment opportunity/affirmative action record-keeping and reporting purposes. Submission of this form by you is voluntary. Please be assured that you will not be subjected to any adverse treatment if you do not provide the information requested. In the event that you do provide the information requested, the information and this form will be processed and maintained separately from your employment application forms and, if you are hired by the company, your personnel file.

• I understand that submission of this form is voluntary.

Self-Identification

• Male
• Female

Minority Status Identification

• White (Non-Hispanic Origin)
• Black (Non-Hispanic Origin)
• Hispanic
• Asian or Pacific Islander
• American Indian or Alaskan Native

Position Sought

Name

First

Last

Date

Submit