MISSOULA URBAN TRANSPORTATION DISTRICT
APPLICATION SELF-IDENTIFICATION FORM
This is a voluntary, confidential form which is kept separate from your application.  The Missoula Urban Transportation District, as a
federal contractor, used this form for obtaining applicant information needed to complete required periodic reports of job applicants
by race/ethnic categories, sex, disability status, and status as a disabled and/or Vietnam Era Veteran.  This information is analyzed to
determine if our selection process assures equal employment opportunity.  We appreciate your cooperation in providing the following
information.
Name:								Sex:	_____ Male	_____ Female
	Last			First			MI
Position applying for:								Department:
Please check if applicable:							Please check ONE of the following:
	HANDICAPPED/DISABLED							WHITE (Not of Hispanic Origin)
	Any person who has a physical or mental impairment							A person having origins in any of the original peoples
	which substantially limits one or more major life							Europe, North Africa, or the Middle East.
	activities, has a record of such an impairment.  "Major
	life activities" means functions such as caring for							BLACK (Not of Hispanic Origin)
	one's self, performing manual tasks, walking, seeing,							A person having origins in one of the black racial
	hearing, speaking, breathing, learning and working.							groups of Africa.
	DISABLED VETERAN							SPANISH (Hispanic)
	A person entitled to disability compensation under							A person of Mexican, Puerto Rican, Cuban, Central or
	laws administered by the Veterans Administration for							South American or other Spanish culture or origin,
	disability rated at 30 per centum or more or a person							regardless of race.
	whose discharge or release from active duty was for a
	disability incurred or aggravated in the line of duty.							ASIAN OR PACIFIC ISLANDER
								A person having origins in any of the original peoples
	VIETNAM ERA VETERAN							of the Far East, Southeast Asia, the Indian sub-
	A person who served on active duty for a period of							continent, or the Pacific Islands.  This area includes,
	more than 180 days, any part of which occurred							for example, China, India, Japan, Korea, Samoa, and
	between August 5, 1964 and May 7, 1975, and was							the Philippines.
	honorably discharged or released therefrom with other
	than a dishonorable discharge or was discharged or							AMERICAN INDIAN OR ALASKAN NATIVE
	released from active duty for a service connected							A person having origins in any of the original peoples
	disability.							of North America, who maintains cultural identification
								through tribal affiliation or community recognition.
Where did you learn about this vacancy?
________ Newspaper             ________ Job Service             ________ Word of Mouth             ________ Other (posting, etc.)
Signature:   ________________________________________________________________									Date:   ______________________
Thank you for taking the time to complete this form.  Please return it with your application to:
Missoula Urban Transportation District, 1221 Shakespeare, Missoula, MT  59802
MUTD IS AN AFFIRMATIVE ACTION/EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER