Part Four

Columbia Gorge Center

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Application Part Four

Addendum to Application for Employment

Equal Employment Opportunity Information

Columbia Gorge Center promotes the employment of people with disabilities. This form is designed to assist
us in that effort. We are also required by state, federal laws, and regulations to furnish statistical data on all
job applicants. We would appreciate your cooperation in providing us with the required information below.

Columbia Gorge Center is an equal opportunity employer. This information will be used for statistical purposes
only. The information is voluntary, and failure to provide it will not affect hiring decisions. It will be separated
from your application form and kept in a confidential file.

Initial here if you choose not to disclose information requested in the section below.

Your Name

Male

Female

African American

Asian/Pacific Islander

Native American

Alaskan Native

Hispanic

Caucasian

Vietnam Era Veteran (who has served more than 180 days of active duty between 08/05/64 and 05/07/75)

Disabled Veteran* (entitled to disability compensation by the Veterans Administration for a disability
rated at 30 percent or more whose discharge was for a disability incurred in the line of duty)

A person with a disability* who (1) has a physical or mental impairment which substantially limits one
or more of the individual's major life activities; (2) has a record of the impairment; or (3) is regarded
as having such an impairment. (The person is "substantially limited" if he or she is likely to experience
difficulty in securing, retaining, or advancing in employment because of a disability.)

For Office Use Only

Employment Application Date

Applicant Hired; completed application

What department was the job he or she applied for in?

Start Date

Starting Wage

Applicant Not Hired

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