EQUAL OPPORTUNITY, AFFIRMATIVE ACTION
VOLUNTARY SELF IDENTIFICATION FORM

Balance, Inc. is an Equal Opportunity and Affirmative Action Employer.  As required by law, we must record certain information to be made a part of our Affirmative Act ion Program.

You are invited to participate in the Affirmative Action Program by reporting their race, gender, veteran status and disability status. In extending this invitation you are also advised that:
(a) employees are under no obligation to respond , but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary data required for our Equal Opportunity Reporting and

Affirmative Action Program. We are a company that values diversity. Refusal to provide this information will have no bearing on your employment status and will not subject you in any adverse treatment.

EQUAL OPPORTUNITY, AFFIRMATIVE ACTION VOLUNTARY SELF IDENTIFICATION FORM

1. Race Check one:

2. Gender

3. Veteran Status

4. Disability Status

5. Referral Source