Employee Self-Identification Form

BROOKS TRACTOR INC., in compliance with the City of Madison, an Affirmative Action Ordinance and their Self Identification Form. The following information is voluntary and allows us to meet government-reporting requirements and evaluate the effectiveness of our recruiting efforts. The information will be kept confidential and when reported, data will not identify an specific individual. Refusal to provide this information will not subject you to any adverse treatment in accordance with Brooks Tractor Inc. policies, which forbid discrimination-based on this information.

General Information

First Name:

Middle Name:

Last Name:

Application for position of:

Department/Branch:

Gender:

Male
Female
Prefer not to disclose

Date of Birth:

Ethnicity and Heritage Code Untitled Title

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Please identify yourself as one of the following:

Hispanic or Latino
Not Hispanic or Latino

Race Definitions

American Indian or Alaska Native:
A person having origins in any of the original peoples of North or South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.

Asian:
A person having origins in any of the orginal peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam.

Black or African American:
A person having origins in any of the black racial groups of Africa.

Native Hawaiian or other Pacific Islander:
A person having origins in any of the original peoples of Hawaii, Guan, Samoa, or other Pacific Islands.

White:
A person having origins in any other original peoples of Europe, the Middle East, or North Africa.

Please identify yourself as one or more of the following races:

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

Self-Identification of Disability

What is a disability?
A person has a disability if he or she has a physical or mental impairment or medical condition that substantially limits a major life activity, or has a history or record of such impairment or medical condition.

Major life activities include, but are not limited to: seeing, hearing, eating, walking, standing, sitting, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and performing manual tasks. Major life activities also include the operation of major bodily functions such as: the immune system, skin, normal cell growth, bowel, bladder, neurological, circulatory, cardiovascular, endocrine, hemic (blood), lymphatic, and reproductive functions.

Please indicate below whether you have a disability:

YES, I HAVE A DISABILITY (or have previously had a disability)
NO, I DO NOT WISH TO IDENTIFY AS HAVING A DISABILITY

Veteran Status

Please Indicate below of your Veteran Status (if applicable):

Non-Veteran
Veteran claiming disability
Veteran
Other

How did you learn of this vacancy?

Please indicate where you learned of this position:

Word of Mouth
Job Net
Craigslist
Indeed
Other

Reasonable Accommodation(s)

If you need reasonable accommodation(s) during the application process due to disability related functional limitations, please notify Brooks Tractor Human Resources at (608) 837-5141; FAX (608) 837-3984; humanresources@brookstractor.com

I need an accommodation in the hiring/examination process:

If yes, accommodation requested is (i.e., extended time, reader, alternative test format, other):

**You will be required to provide written verification from a doctor or other authorized person confirming your disability and indicating reasonable accommodation.

Application Certification Statement

I certify that all answers to questions in this application are true, and I agree that any and all misstatements or omissions of material fact will cause forfeiture on my part to all rights to any employment to Brooks Tractor Inc.

Application Signature:

Date: