INNER CITY BROADCASTING SOUTH CAROLINA (ICBSC) Applicant Profile Data Form We request this information in order to meet EEO requirements of the Federal Communications Commission. It will be maintained in a file separate from your application and will not be considered in connection with your application. Please complete and check items applicable to you. A. Name: _________________________ Date:_______________________ B. Vacancy applied for (Job Title): __________________________________ C. Date you submitted application or resume: _____________________________ D. Male _____ Female_____ ( ) White, not of Hispanic Origin - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. ( ) Black, not of Hispanic Origin - A person having origins in any of the black racial groups of Africa. ( ) Hispanic - A person of Mexican, Puerto Rican, Central or South American or other Spanish culture or origin, regardless of race. ( ) Asian or Pacific Islander - A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa. ( ) American Indian or Alaskan Native - A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. E. What prompted you to apply? (Please check the primary reason only.) Advertisement Non-Employee Referral Agency Self Community Organization School Employee Referral Web Site Other _________________ F. Please identify the referral source by name, and provide any additional contact information you know about that source or that is applicable to your situation, including address, phone, e-mail and contact person: ________________________________________________________ ________________________________________________________ ________________________________________________________ [For station use only] Referral Source entitled to notification upon request? Yes ( ) No ( ) Applicant Hired? Yes ( ) No ( ) If yes, date accepted: _______________