Employee
and Applicant SelfIdentification Form
TO BE COMPLETED BY ALL NEW EMPLOYEES AND APPLICANTS
Date of Application:
Name: Position Applying For:
ICI, LLC’s employment practices are conducted without regard to race, color, religion, gender, national origin, citizenship, age,
mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all
applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.
To successfully implement this program and respond to federal and state affirmative action reporting requirements, it is important
that the following information be gathered from all employees and applicants. Providing this information is optional. Failure to
submit data will not in any way affect your present or future employment. The information provided will remain confidential and
be used for government reporting purposes only.
Gender: Male Female
Racial/Ethnic Heritage: If you do not provide the racial/ethnic heritage information, federal regulations stipulate that a visual
survey or postemployment records may be used to acquire racial/ethnic heritage information necessary for the completion of
affirmative action records.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture of 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 Alaskan Native (Not Hispanic or Latino) – A person having origins in any of the
original peoples of North and 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.
Are you a Veteran?: Yes No
I am a Vietnam Era Veteran
I am a Veteran of the U.S. Armed Forces (Refer to list on reverse side)
Special Disabled Veteran
Disability/Handicap Yes No
The Rehabilitation Act of 1973, as amended, defines an “Individual with a Disability” for purposes of the program as any person
who (a) has a physical or mental impairment which substantially limits one or more of such person’s major life activities; (b) has
a record of such impairments; or (c) is regarded as having such impairment.
For Administrative Use Only
Employee Applicant
Date of Hire: Location: Job Title:
Completed By: Date:
Marine
CAMPAIGN/EXPEDITION Start Date End Date Army Navy Air Force Corp Coast Guard
Campaign or Service Medals
American Defense Service 09/08/39 12/07/41 X X X X
Army Occupation of Austria 05/09/45 07/27/55 X X
Army Occupation of Berlin 05/09/45 10/02/90 X X X X X
Army Occupation of Germany 05/09/45 05/05/55 X X X X
Army Occupation of Japan 09/03/45 04/27/52 X X X X X
China Service 07/07/37 09/07/39 X X
China Service Medal (Extended) 09/02/45 04/01/57 X
Korean Service 06/27/50 07/27/54 X X X X X
Navy Occupation of Trieste 05/09/45 10/25/54 X X X
Navy Occupation of Austria 05/08/45 10/25/55 X
Navy Occupation of Berlin 05/08/45 10/02/90 X X
Navy Units of the Sixth Fleet 05/09/45 10/25/55 X
SW Asia Service Medal(Desert Shield/Storm) 08/02/90 11/02/95 X X X X X
Vietnam Service Medal (VSM) 07/04/65 03/28/73 X X X X X
Armed Forces Expeditionary Medal (AFEM)
Berlin 08/14/61 06/01/63 X X X X X
Bosnia and Herzegovina (Joint Endeavor) 11/20/95 12/20/96 X X X X X
Bosnia and Herzegovina (Joint Guard) 12/20/96 Present X X X X X
Cambodia 03/29/73 08/15/73 X X X X X
Cambodia Evacuation (Eagle Pull) 04/11/75 04/13/75 X X X X X
Congo 07/14/60 09/01/62 X X X X X
Congo 11/23/64 11/27/64 X X X X X
Cuba 10/24/62 06/01/63 X X X X X
Dominican Republic 04/28/65 09/21/66 X X X X X
El Salvador 01/01/81 02/01/92 X X X X X
Grenada (Urgent Fury) 10/23/83 11/21/83 X X X X X
Haiti (Uphold Democracy) 09/16/94 03/31/95 X X X X X
Iraq (Northern Watch) 01/01/97 Present X X X X X
Korea 10/01/66 06/30/74 X X X X X
Laos 04/19/61 10/07/62 X X X X X
Lebanon 07/01/58 11/01/58 X X X X X
Lebanon 06/01/83 12/01/87 X X X X X
Libyan Area (Eldoredo Canyon) 04/12/86 04/17/86 X X X X X
Mayaquez Operation 05/15/75 05/15/75 X X X X X
Panama (Just Cause) 12/20/89 01/31/90 X X X X X
Persian Gulf (Earnest Will) 07/24/87 08/01/90 X X X X X
Persian Gulf 08/02/90 01/02/92 X X X X X
Persian Gulf (Southern Watch) 12/01/95 Present X X X X X
Persian Gulf (Vigilant Sentinel) 12/01/95 02/15/97 X X X X X
Persian Gulf Interception Operation 12/01/95 Present X X X X X
Quemoy and Matsu Islands 08/23/58 06/01/63 X X X X X
Somalia (Restore Hope) 12/05/92 03/31/95 X X X X X
Taiwan Straits 08/23/58 01/01/59 X X X X X
Thailand 05/16/62 08/10/62 X X X X X
Vietnam and Thailand 07/01/58 07/03/65 X X X X X
Vietnam Evacuation 04/29/75 04/30/75 X X X X X
Navy Expeditionary Medal & Marine Corp
Expeditionary Medal
Cuba 01/03/61 10/23/62 X X
Indian Ocean/Iran 11/21/79 10/20/81 X X
Iranian/Yemen/Indian Ocean 12/08/78 06/06/79 X X
Lebanon 08/20/82 05/31/83 X X
Liberia (Sharp Edge) 08/05/90 02/21/91 X X
Libyan Area 01/20/86 06/27/86 X X
Panama 04/01/80 12/19/86 X X
Panama 02/01/90 06/13/90 X X
Persian Gulf 02/01/87 07/23/87 X X
Rwanda (Distance Runner) 04/07/94 04/18/94 X X
Thailand 05/16/62 08/10/62 X X
