Voluntary Self Identification (Committee Apps)

2. Date*

4. Voluntary Self Identification

6. The following information is voluntary and allows us to track the composition of our commissions. We value committees, commissions, and boards that demographically reflect the community. To ensure we reflect the community, we count on you to provide us your demographic information. The information will be kept confidential and when reported data will not identify any specific individual. Refusal to provide information will not subject you to any adverse treatment.

   The following information is voluntary and allows us to track the composition of our commissions. We value committees, commissions, and boards that demographically reflect the community. To ensure we reflect the community, we count on you to provide us your demographic information. The information will be kept confidential and when reported data will not identify any specific individual. Refusal to provide information will not subject you to any adverse treatment.

8. Please make selections for EACH question

10. Ethnicity

    1. Hispanic or Latino
    2. Not Hispanic or Latino
12. Race (select one or more)

    1. American Indian and Alaska Native
    2. Asian
    3. African American

    1. Native Hawaiian and Other Pacific Islander
    2. White
    3. Some other race not listed above

14. Do you have a disability?

    1. Yes
    2. No

    Physical or mental impairment that limits a major life function, or record of such impairment.

16. Gender

18. Date of Birth

Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit Submit and Print

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