Copy of SELF-IDENTIFICATION FORM FOR APPLICANT FLOW DATA Q1 2022

It is the policy of Talley Construction Company, Inc to provide equal employment opportunity to all employees and applicants for employment without regards to race, color, religion, national origin, age, sex, gender, pregnancy, disability, sexual orientation, gender identity, genetic information, military status, veteran status, or other classification protected by applicable federal, state, or local laws.

Various agencies of The United States Government require employers to collect information on applicants. Information requested on this sheet is for purposes of compliance with these recordkeeping requirements and to determine recruiting and employment matters. If you wish to be identified, please provide any of the information requested on this form that you would like to submit. You may submit this information now or at any time in the future.

Such information will in no way affect the decision regarding your application for employment. This sheet will be kept confidential and maintained separately from your application form.

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* 1. Name

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* 2. Date

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* 3. Position Applied For

Completion of the following is voluntary and is not a requirement for employment.

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* 4. Gender

Male

Female

I do not wish to self-identify

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* 5. ETHNICITY CLASSIFICATION (please choose only one)

Hispanic or Latino: Person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish descent.

African American/Black: Having origins in any of the Black racial groups of Africa

Asian: Person of Japanese, Chinese, Korean, Vietnamese, Asian Indian, Thai or similar descent other than Pacific

Islander or Filipino.

Pacific Islander: Person of Hawaiian, Samoan, Guamanian, Polynesian, Fiji or Tahitian descent

Native American: Person of American Indian, Eskimo, or persons of origins in any of the original peoples of North and

South America (including Central America), who maintains a tribal affiliation and community attachment

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

Two or More Races: Persons who identify with more than one of the above races.

I do not wish to self-identify

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* 6. Disability Status - Do you have a disability?

Yes

I do not wish to self-identify

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* 7. Veteran Status

I am a veteran

I am not a veteran

I do not wish to self-identify