Red text and boxes with yellow shading are REQUIRED fields.
As an equal opportunity employer, Professional Nursing Service must file an annual EEO 1 report in compliance with federal law. It is therefore necessary for us to request the following information. This information is strictly for record keeping and reporting purposes as required by government regulations. No information provided on this form will be used as a factor in any employment related decisions. Professional Nursing Service is an equal opportunity employer and makes all employment related decisions without regard to race, sex, age, marital status, veteran's status, political affiliations, national origin, ancestry, medical condition, disability status or any other legally protected status. this form will be kept separate from personnel files. You are not obligated or required to complete and return this form to us. The fact that you do or do not complete the form will not affect your application in our hiring process.
Personal Information:
First Name:	Middle Initial:
Last Name:
Social Security #:
Gender:	Male     Female
Race:	White (not of Hispanic origin)     Black (not of Hispanic origin)   Hispanic     Asian or pacific Islander   American Indian / Alaskan Native
Handicapped:	Yes     No
Veteran:	Yes     No
If YES:	WWII     Korea   Vietnam     Other
If Other, specify:
	Date Submitted:

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