Purdue Research Foundation is an Equal Opportunity/Equal Access/Affirmative Action Employer and complies with all applicable federal and state regulations. We are required to solicit the information indicated below. This information is kept for statistical reporting and federal EEO/AA requirements. Your responses are voluntary and your cooperation in providing this information is appreciated. Failure to provide the following information will not result in an adverse employment action. Responses to the following questions are mandatory Information First Name: Last Name: Position you are applying for: Where did you learn about this position? Gender Male Female Non-Binary Responses to the following questions are voluntary Ethnicity Hispanic or Latino — Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Not Hispanic or Latino I prefer not to answer Race American Indian or Alaska Native — Persons having origins in any of the original peoples of North and South. Asian — Persons having origins in any of the original 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 — Persons having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander — Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White — Persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. Two or More Races I prefer not to answer Veterans I am a veteran I am not a veteran I prefer not to answer Disabled Veteran A DISABLED VETERAN IS: 1. A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or 2. Was discharged or released from active duty because of a service-connected disability. Other Protected Veteran AN OTHER PROTECTED VETERAN IS: A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Armed Forces Service Medal Veteran AN ARMED FORCES SERVICE MEDAL VETERAN IS: A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 FR 1209, 3 CFR, 1996 Comp., p. 159). Recently Separated Veteran A veteran who was discharged or released from active duty in the U.S. military, ground, naval or air service within the last three years. I prefer not to answer Disability Yes, I have a disability, or have a history/record of having a disability No, I do not have a disability, or a history/record of having a disability I prefer not to answer Responses to the following questions are mandatory Eligibility Are you legally eligible for employment in the United States? Yes No Off-CampusEmployment Are you eligible for off-campus employment? Yes No Note: PRF is an off-campus employer. Education Name of Institution: Date Received Degree / Diploma (MM/DD/YYYY): Diploma or Degree: Field of Study: The information I have provided to Purdue Research Foundation, including, but not limited to, the information on my resume, is true and complete to the best of my knowledge. Providing false or misleading information, or failing to provide material information at any time during the employment process may result in the termination of my candidacy and/or employment with Purdue Research Foundation. Furthermore, if I am convicted of or plead guilty to a crime after I complete this form, I will report the conviction or guilty plea to PRF Human Resources immediately. AGREE Submit
