State of New York Unified Court System I I ucs-1ex (3/08)

UAL EMPLOYMENT OPPORTUNITY DATA COLLECTION FORM

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Marking lnstructions:. Use a No. 2 penci l or blue or black ink pen only.. Do not use pens with ink that soaks through the paper.. Make solid marks that fill the oval completely. INCORRECT. Make no stray marks on this form. @ @ O O

COHHECTI

Completion of this form is voluntary for all applicants for positionswithin the New York State Unified Court System. The informationprovided is f i led with the Office of Court Administration and ismaintained separately and confidentially. The information is notused for selection purposes but only to evaluate the success of thecourt system's equal employment opportunity efforts. Do not sendthis form with the iob applicaiion. Please fold as indicated, placein an envelope and forward to the address shown on the back.

DISABLED - Do you have a physical or mentalimpairment which substant ia l ly l imi ts one ormore major l i fe activit ies or have a record ofsuch impairment or have been classi f ied asdisabled by a school or agency?

C) Yes O t'to

DO YOU LIVE IN NEW YORK STATE?OYes O No

11. IF YOU I-IVE IN NEW YORK STATE. PLEASEINDICATE COUNilO 1 Albany C)22 Herkimer(J 2 Allegany a-)23 JeffersonCr 3 Bronx O24 Kings (Bklyn.)

Q 4 Broome C-l25 Letl s

O 5 C, jL d dugus C-)26 l i \ nostorC-) 6. Cayuga Cr27 MadisonC-) 7 Chauta!qua C)28 l \40nroeC-) I Chemung Q29 MontgomeryC-) I Chenango C-)30 Nassa!a-) l0 Cl inton O31 New York ( | \ /an.)

C-)11 Co umbia O32 N agaraC)12 Cort land Cr33 OneidaC)13 Delaware a-)34 0nondaga

Q14 Durc 'ess C)35 0nra-,0C-)15 Er ie C)36 Orangeal l6 Essex a)37 OrleansC-)17 Frankl in Q38 OsvregoC-)18 Ful ton Cf39 Otsegoa-)lg Genesee C-)40 Putnaff)al20 Greene C-)41 Oueensa-)21 Hamiton C)42 Rensselaer

O 43 Richmond (S l )

- )

44 Rockiand

C) 45 St. Lawrence

O 46 SaratogaC) 47 Schenectady

O 48 Schohar ie

Q 49 Schuyler

O 50 Seneca

O 51 Steuben

Q 52 Suffolk

QS3SulvanO 54 Tioga

O 55 Tompklns

O 56 Ulstera-) 57 Warren

O 58 Washington

Q 59 WayneC) 60 Westchester

Q 61 Wyoming

C) 62 Yates

12. JOB INFORMATION SOURCE:How did you f ind out about th is job?C) a. Posted notice at a court faci l i tyO b. Posted notice at another publ ic faci l i tyO c. Unif ied Court System Employment Hotl ineC d. Recruitment visi t from U.C.S. representativeO e. Job kioskC) f . Career or job fairO g, Friend or relat ive employed by U.C.S.O h. School (guidance counselor or placement service)O i. Union or fraternal organizationO J. Minority or women's professional organizationO k. Local newspaper

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1. RECRUITMENT STAGE (MARK ONE ONLY)O a. Examination Application O c. Job Application O e. AppointmentO b. Day of Examrnation (f d. Job Interview

2. JOB TITLE

ANNOUNCEMENT SOCIAL SECURITY YEAR OFNUMBER NUMBER BIRTH

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GENDER (J Male O Female

HIGHEST LEVEL OF EDUCATION COMPLETED (MARK ONE ONLY)O a. Less than High School Graduation O g. Graduate Study BeyondO b. High School or Equivalency Diploma Bachelor 's DegreeO c.2-Yr. Col lege (No degree) O h. Master 's DegreeO d. Associate's Degree O i. Graduate Study Beyond Master 'sO e. +-Yr. College (No degree) O j . DoctorateO f. Bachelor 's Degree O k. Law Degree

RACE/ETHNIC OBIGIN (MARK ONE ONLY)O a. White

(Not of Hispanic Origin): Al l persons having origins in any of the originalpeoples o{ Europe, North Af r ica, or the Middle East.

O b. Black(Not of Hispanic Origin): Al l persons having origins in any of theBlack racial groups of Af r ica.

O c. HispanicAll persons of Mexican, Puerto Rican, Cuban, Central orSouth American, or other Spanish culture or origin, regardless of race.

O d. Asian or Pacif ic lslanderAll persons having origins in any of the original peoples of the FarEast, Southeast Asia, the Indian Subcontinent, or the Pacif ic lslands.This area includes, for example, China, Japan, Korea, the Phil ippinelslands, and Samoa

(J e. American Indian or Alaskan NativeAll persons having origins in any of the original peoples of NorthAmerica, and who maintain cultural identi f icat ion through tr ibalaff i l iat ion or communitv recoonit ion.

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8. SAMPLE

PLEASE FOLD ALONG DASH LINE - DO NOT TAPE OR STAPLE SHUT __--___

SEND TO:OFFICE OF COURT ADMINISTRATIONEEO DATA COLLECTION17 ELK ST., sTH FLOORALBANY NY 12207-1014

PLEASE FOLD ALONG DASH LINE - DO NOT TAPE Oft STAPLE SHUT -------SAMPLE