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Applicants are considered for positions and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, height, weight, legal alien status, non-disqualifying disability or any other protected characteristic.

Solely to help us comply with government reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation.

This data will be kept separate from the Application for Employment. Data provided on this form will in no way impact hiring or other employment decisions by CELC.

Position Applies For:	Director Lead Teacher Associate Teacher Assistant Teacher Substitute Teacher
Full Time:	Part Time:
Date: (DD/MM/YYYY)
Referral Source:	Advertisement Friend Relative Walk In
Name of Advertisement:
First Name:
Last Name:
Middle Name:
Address 1:
Address 2:
City:
State:	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip:
Telephone:
Email:

AFFIRMATIVE ACTION SURVEY

Government agencies require periodic reports on the gender, ethnicity, disability and veterans status of applicants.