LA CENTER SCHOOL DISTRICT NO. 101
725 Highland Road     PO Box 1840
La Center, WA 98629

Date:

VOLUNTARY, CONFIDENTIAL INFORMATION 
FOR AFFIRMATIVE ACTION PURPOSES

Information derived from this questionnaire is for statistical purposes and will not be filed with or made part of your application or personnel file. La Center School District No. 101 is committed to ensuring equal employment opportunities for all persons without regard to the presence of any sensory, mental or physical disability, except as may be necessary to meet a bona fide occupational qualification.

Name:____________________________________

Address:__________________________________

Position Applying For:______________________________

Information:

Male

Female

Racial/Ethic Group:

American Indian or Alaskan Native

Asian or Pacific Islander

Black, not of Hispanic Origin

Hispanic

White, not of Hispanic Origin

Protected Age Group (40-70 years)

Disabled Veteran / Vietnam-era Veteran/or more recent military action 

La Center School District No. 101 complies with all federal rules and regulations and does not discriminate on the basis of race, color, national origin, sex or disability. This holds true for all district employment opportunities. Inquiries regarding compliance and/or grievance procedures may be directed to the district's Title IX Officer and Section 504 Coordinator, ADA c/o Superintendent at the above address.