APPLICANT FLOW RECORD

Date Received: _________________

Please submit this completed form with your application form. The information will be used solely for Equal Employment Opportunity (EEO) purposes in compliance with State and Federal laws and guidelines.

Name: ______________________________ Soc. Sec. #: _______________________

Classification/Job for which you are applying: _________________________________

How did you learn about this position? _______________________________________

________ Male _________ Female

Birthdate: ____________________

Please Check:

A) __________ White Persons having origin in any of the original people of Europe, North Africa or Middle East.
B) _________ Black Persons having origin in any of the Black racial groups
C) __________ Hispanic Persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origins regardless of race.
D) __________ American Indian or Alaskan Native Persons having origins in any of the original people of North America and who maintain cultural identification through tribal affiliation or community recognition.
E) __________ Asian/Pacific Islanders Persons having origins in any of the original peoples of the Far East, Southeast Asia, Indian Subcontinent, or the Pacific Islands.
F) __________ Handicapped Individual with a physical condition that limits his/her ability to attain employment.


THIS SECTION OF THE FORM IS TO BE COMPLETED BY THE INTERVIEWER. DO NOT FILL IN.

Date of first interview: ___________________ Date of second interview: ____________________

Was a job offer made to this applicant? _____Yes _____ No

If yes, did they accept the job? _____Yes _____No If yes, date of hire: ____________________

If no to either question, list why: ____________________________________________________

_______________________________________________________________________________

Name of interviewer(s): ________________________________

Name of person making employment decision: ______________________________

SPECIAL NOTE: The applicant flow record will be kept separate from the applicants resume or application.