Demographic Request. The following form was used to collect required data on Key Community Contacts and nonelected committee members. OCTS is required by Title VI of the Civil Rights Act of 1964 and related authorities to record demographic information on members of its boards and committees. Please provide the following information: Gender: Male Female Age: Less than 18 45‐64 18‐29 65 and older Disability: Yes No 30‐44 DocuSign Envelope ID: 3FDDF183‐DE0C‐45F5‐AE17‐0B9CF99E613F Completed forms will remain on file as part of the public record. For more information regarding Title VI or this request, please contact the OCTS at 919‐245‐2008 or by email at xxxxxxxxxxxxxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx. Please sign below acknowledging that you have completed this form. Thank you for your participation!
Demographic Request. The following form was used to collect required data on Key Community Contacts and nonelected committee members. Yadkin Valley Economic Development District Inc. /YVEDDI Public Transportation is required by Title VI of the Civil Rights Act of 1964 and related authorities to record demographic information on members of its boards and committees. Please provide the following information: Race/Ethnicity: White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander Hispanic/Latino Other (please specify): National Origin: (if born outside the U.S.) Mexican Central American: South American: Puerto Rican Chinese Vietnamese Korean Other (please specify): Gender: Male Female Age: Less than 18 45-64 Disability: Yes No 00-00 00-00 65 and older Completed forms will remain on file as part of the public record. For more information regarding Title VI or this request, please contact the Yadkin Valley Economic Development District Inc. /YVEDDI Public Transportation at 000-000-0000 or by email at xxxxxxxxxx@xxxxxx.xxx Please sign below acknowledging that you have completed this form. Thank you for your participation! • Forms will be completed prior to NCDOT Title VI reviews and remain on file for three years. • All new and existing members of appointed decision-making boards or committees will be required to complete this form for reporting purposes. • If a member, for whatever reason, selects “I choose not to provide any of the information requested above,” this will be accepted as a completed form. • If a member chooses not to provide any of the information on the form, the Title VI Coordinator will be permitted to indicate that member’s race and gender, based on the Coordinator’s best guess. • Data from these forms will be used to complete the Demographic Request Table. • Once a new member submits this form, the Demographic Request Table for the associated committee will be updated.
