Applicant Control Card

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.

UND complies with the Drug Free Workplace Act.  UND complies with the Jeanne Clery Disclosure of Campus Security Policy & Campus Crime Statistics Act, see at www.police.und.edu/stats/html.

Complete the form and then hit SUBMIT. If you have any questions, please e-mail the Affirmative Action Office at und.affirmativeactionoffice@und.edu or call us at (701) 777-4171. Thank you.
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Date:	Last Name:	First Name:
Address:		City:
State: Please Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Country: Please Select One United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Zip Code:	Position Applied for:
Department:	Title:	Position No.
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?

              

If you would prefer to fill out this card and send to the Affirmative Action by mail: applicant control card/applicant control card.  Send to: Affirmative Action Office, University of North Dakota, 264 Centennial Drive, Stop 7097, Grand Forks, ND 58202-7097. Thank you.