Ethnicity. (Select one): 12b. Race (Select one or more, regardless of ethnicity): 12c. Are you a Military Vetera 1D American Indian or Alaskan Native Active Duty Military? Yes 12d. Do you have a disability? Yes Origin 13. NAME (Last, First) 14. PHONE 15. EMAIL ADDRESS 16. STREET ADDRESS, XXX# 00. CITY 18. STATE 19. ZIP CODE 20. NAME OF AGENCY/ BUREAU 21. AGREEMENT# 22. AGENCY CONTACT NAME (Last, First) 23. AGENCY CONTACT EMAIL & PHONE 24. REIMBURSEMENTS APPROVED: D Yes Type and Rate of Reimbursement:
Ethnicity. This Contract shall not be executed until the Contractor has completed the Minority/Ethnicity Form.
Ethnicity. (Select one): Hispanic or Latino Not Hispanic or Latino 14b. Race (Select one or more, regardless of ethnicity): American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander 14c. Are you a Veteran? Yes No 14d. Do you have disability? Yes No 15. NAME (Last, First) 16. PHONE Home: Mobile: 17. EMAIL ADDRESS
Ethnicity. (Select one): Hispanic or Latino Not Hispanic or Latino 14b. Race (Select one or more, regardless of ethnicity): American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander 14c. Are you a Veteran? Yes No 14d. Do you have disability? Yes No 15. NAME (Last, First) 16. PHONE Home: Mobile: 17. EMAIL ADDRESS 18. XXXXXX XXXXXXX 00. XXXX, XXXXX, ZIP CODE 20. AGENCY CONTACT NAME (Last, First) Xxxxxx, Xxxxxx 21. AGENCY CONTACT EMAIL & PHONE 000-000-0000 xxxxxx_xxxxxx@xxx.xxx 22. REIMBURSEMENTS APPROVED: Yes No Type and Rate of Reimbursement: N/A 23. VOLUNTEER POSITION/GROUP PROJECT TITLE:
Ethnicity. (Select one): Hispanic or Latino Not Hispanic or Latino 14b. Race (Select one or more, regardless of ethnicity): American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander 14c. Are you a Veteran? Yes No 14d. Do you have a disability? Yes No 15. NAME (Last, First) 16. PHONE Home: Mobile: 17. EMAIL ADDRESS 18. XXXXXX XXXXXXX 00. XXXX, XXXXX, ZIP CODE 20. AGENCY CONTACT NAME (Last, First) 21. AGENCY CONTACT EMAIL & PHONE 22. REIMBURSEMENTS APPROVED: Type and Rate of Reimbursement: Yes No 23. VOLUNTEER POSITION/GROUP PROJECT TITLE:
Ethnicity. 4. Gender
5. Social Security Number or Alien Registration
6. Disabled or handicapped status
Ethnicity. For non-Hispanics only:
Ethnicity. Are you … (check all that apply)
Ethnicity. 8. Gender
9. Social Security Number or Alien Registration 10. Disabled or handicapped status
1. Household composition including number of adults, number of children and legal name of the head of household
2. Gross Annual Household Income
3. Current and/or previous housing history (for program eligibility, if applicable)
1. Date of birth of the head of household 2. Race
Ethnicity. Number of current children;
