APPLICATION RECORD
Name:
Position applied for:
Date:


In order for Dixie State College to protect its populace and property, applicants are required to answer the following question:
Have you ever been convicted of a felony? YES or NO
If yes is marked, you are required to complete an additional form.
If not a U.S. citizen, state visa type and expiration:
Your response to the following questions is optional. The information will assist Dixie State College in completing its equal opportunity/affirmative action reports to the federal government and in its affirmative action program. Dixie State College complies with the Americans with Disabilities Act and Utah's Veterans Preference legislation.
Please check the following descriptors which apply to you (see definitions):


Female Male Disabled
Vietnam Era Veteran Veteran-Other Disabled Veteran
American Indian/Alaska Native Asian or Pacific Islander Hispanic
Black White Other


Definitions:

Disabled: an individual having a physical or mental impairment which substantially limits one or more life activities. Provide documentation.

Vietnam Era Veteran: an individual who served at least 180 days in the armed forces between August 5, 1964 and May 7, 1975. Provide documentation (DD-214 form).

Veteran-Other: an individual who served on active duty in the armed forces for more than 180 consecutive days, or was a member of a reserve component which served in a campaign or expedition for which a campaign medal has been authorized and who has been separated or retired under honorable conditions. Provide documentation (DD-214 form).

Disabled Veteran: an individual who has been separated or retired from the armed forces, under honorable conditions, and establishes the existence of a service-connected disability or is receiving compensation, disability retirement benefits, or pension because of a public statute administered by the federal Department of Veterans Affairs or a military department. Provide documentation (DD-214 form).

American Indian or Alaskan Native: persons having origin in the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islander: persons having origin in the original peoples of the Far East, Southeast Asia, Indian subcontinent, or Pacific Islands.

Hispanic: persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

Black: persons having origin in the black racial groups of Africa.

White: persons having origin in the original peoples of Europe, North Africa, or the Middle East.

Other: persons having origin not covered by the above categories.