Applicant Control Card
FACULTY AND ACADEMIC STAFF

The following voluntary information is used to monitor our Affirmative Action Program. The information you are being asked to provide is the result of a federal requirement under Executive Order 11246. It will be used for reporting of applicant flow statistics and determining effective methods of advertising. Employees and applicants for employment who wish to benefit under the affirmative action programs for qualified disabled persons and Vietnam Era/Special Disabled Veterans are invited to self-identify. The information is voluntary, will be kept confidential, and will not subject the applicant or employee to any adverse treatment. The information is used in accordance with Section 503 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended. Please note that a request to benefit under the affirmative action program may be made immediately or at any time in the future.

Complete the form and then hit SUBMIT. If you have any questions, please e-mail the Affirmative Action Office at affirmativeaction@mail.und.nodak.edu or call us at 701-777-4171. Thank you.

Date:    
Last Name: First Name:
Address:
City: State: Zip:
Country:  
Position Applied for:  
Title:
Position No.
Department:
SEX
Male
Female
DISABLED
Yes
No
AGE
18-39
40 or over
RACE (Check all that apply)
White
Black or African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Vietnam Era Veteran
No
Yes (DD 214 Required)
Disabled Veteran
No
Yes (VA certification Required)

How did you hear about this position?