Amphion Medical Solutions
Amphion Medical Solutions
   
    Affirmative Action Form  
   

 

Our organization is committed to the employment and advancement of minorities, females, individuals with disabilities, and veterans. If you fall into one of these protected classifications, we invite you to identify yourself and receive coverage under our company’s Affirmative Action Plan. You may inform us of your desire to benefit under the program at this time and/or any time in the future.

Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts.

Applicant Name:

Email:
Date:
Position Applied For:
Please Check One:Male Female
Indicate the Appropriate Race/Ethnic Group:White
Asian
Hispanic or Latino (All Races)
Black/African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino (White Race Only)
American Indian or Alaskan Native
Hispanic or Latino (All Other Races)
How Were You Referred To This Job:Advertisement
School/College
Employee Referral
State Job Service
Employment Agency
Temporary Agency
Government Agency
Walk In
Recruiter
Other
 Please Specify:
  
 
 

 
 



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