Equal Employment Opportunity FormLinkedInThis field is for validation purposes and should be left unchanged.The following information is gathered solely for the purpose of reporting data on race and ethnicity to meet federal and state requirements and will not be used to evaluate the applicant’s qualifications, suitability or desirability for employment.Last Name:*First Name:*Middle Name:Date of Birth:* Social Security Number:*###-##-####Driver's License Number:Please list two letter state abbreviation if not part of the number. (Ex. AL 123456789)Are you Hispanic/Lationo? (chose only one) Yes NoGender: Male FemaleWhat is your race? (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander WhiteHave you ever been employed by the Jimmie Hale Mission? Yes NoWhat position?Which location/program?Employed from date:mm/yyyyEmployed to date:mm/yyyyHave you ever been a resident or client of the Jimmie Hale Mission? Yes NoWhich location/program?Resident from date:mm/yyyyResident to date:mm/yyyyHave you ever been convicted of, or pleaded no contest or guilty to, any crime involving theft, dishonesty, violence or sexual misconduct?* Yes NoExplain below: Once you click SUBMIT, please do NOT click the back button, refresh the page, or close the tab/window as this can interfere with proper form submission.
