Applicant Voluntary Self-Identification Form

Applicants are considered for all positions for which they qualify without regard to race,
color, age, national origin, sex, sexual orientation, or disability.
Kennedy Valve complies with applicable federal and state laws, including affirmative action
regulations and responsibilities.
Solely to help
Government us comply
agencies with required
require periodic reports onrecord-keeping, reporting
the sex, ethnicity, disability and other
and veteran statuslegal
of applicants. This
data is for analysis please
requirements, and affirmative
fill outaction only. Submission
the Applicant Data ofRecord.
informationWe is appreciate
VOLUNTARY.your cooperation.
This data is for periodic government reporting and will be kept in a Confidential File separate
from the Application for Employment. It will not be used in considering and/or selecting
applicants for employment. Submission of this information is voluntary, and your refusal to
provide it will not affect your application for employment or subject you to any adverse

Name: Hervy Marquez Position(s) Applied For: Quality Manager Date:28-Oct-10

Gender (Check One):

X Male Female

Please indicate your ethnicity/race by selecting one option under Ethnicity/Race. If you are Hispanic or
Latino, please select the Hispanic or Latino category. If you are not Hispanic or Latino, please select one of
the other categories. Please mark as appropriate the categories under the Veteran Status section.
(See definitions on page 2)

Race/Ethnic Group (Check One):

X Hispanic or Latino

White (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)

Asian (Not Hispanic or Latino)

American Indian or Alaska Native (Not Hispanic or Latino)

Two or More Races (Not Hispanic or Latino)

Check One if Applicable:

Vietnam Era Veteran
Special Disabled Veteran
Other Protected Veteran Date of Military discharge:________________
DEFINITIONS FOR VOLUNTARY IDENTIFICATION

ETHNICITY / RACE

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture
or origin regardless of race.

White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.

Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of
Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino) – A person 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.

American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples
of North or South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races).

VETERAN STATUS

Special Disabled Veteran – A veteran who is entitled to compensation under the laws administered by the Veteran's
Administration, or a person who was discharged or released from active duty because of a service-connected
disability.

Vietnam Era Veteran – Any individual who served on active duty in the military for a period of more than 180 days any
part of which occurred between February 28, 1961 and May 7, 1975 or was discharged with other than dishonorable
discharge between February 28, 1961 and May 7, 1975.

Other Protected Veteran – Any individual who served on active duty during a war or in a campaign or expedition for
which a campaign badge has been authorized.

1273998.1