P & P No. 802.05

Page 4

Form D

Affirmative Action

Selection of the Individual for the Position

Title of Position:

Department: Supervisor:_______________________

Date:____________________________________

1.0 List the top 3 to 5 candidates for the position:

Date

Race

Sex

No

Non-Citizen

Applicant Name

of App.

Blk

As

AI

H

Mlti

W

M

F

Disabled

Vet

Info

Non-Perm. Resident

2.0 Who is to be offered this position?

3.0 Provide a brief statement as to why this individual was selected:

4.0 Was this position offered to a minority candidate who did not accept the job? _____ Yes _____ No

If yes, explain:

AA Officer Comments:

AA/EEO Officer Date