UNIVERSITIES SPACE RESEARCH ASSOCIATION

______________________________________________________________________________

EQUAL EMPLOYMENT OPPORTUNITY DATA

______________________________________________________________________________



Application Date __________________________

TO BE COMPLETED BY APPLICANT:

Completion of this form is entirely voluntary, and all information will remain confidential and will not affect your application for employment. We are required by law to collect this information for equal opportunity employment purposes, and it will not become part of your personnel record if you are hired by this company.

NAME: __________________________________________________________

SEX:     Male      Female

RACE/ETHNICITY:  American Indian or Alaska Native  
                                     White
                                     Asian Hispanic or Latino (all races)
                                     Black or African American
                                     Hispanic or Latino (White Race only)
                                     Native Hawaiian or Other Pacific Islander
                                     Hispanic or Latino (all other races)

Government contractors must take affirmative action to employ veterans and individuals with a disability. Completion of the following information is voluntary, and will assist us in proper placement and reasonable accommodation. If you wish to be identified as qualifying for such placement or accommodation, please check where applicable:


                                     Vietnam Era Veteran
                                     Individual with a Disability
                                     Disabled Veteran    Check if accommodation is needed
                                     Other Veteran (see reverse side)



TO BE COMPLETED BY EMPLOYER:

Position applied for: ____________________________

EEO-1 Category:

      1. Officials and managers
      2. Professionals
      3. Technicians
      4. Sales
      5. Office and clerical
      6. Crafts - skilled
      7. Operatives - semi-skilled
      8. Laborers - unskilled
      9. Service workers

Employer information completed by:

____________________________________________________    ____________________

Name                                                                                                    Date