AA_ Supplement.pdf

Form AA302 Rev. 11/11

STATE OF NEW JERSEY

Division of Purchase & Property Contract Compliance Audit Unit

EEO Monitoring Program

EMPLOYEE INFORMATION REPORT

IMPORTANT-READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORM. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND TO SUBMIT THE REQUIRED $150.00 FEE MAY DELAY ISSUANCE OF YOUR CERTIFICATE. DO NOT SUBMIT EEO-1 REPORT FOR SECTION B, ITEM 11. For Instructions on completing the form, go to:

http://www.state.nj.us/treasury/contract_compliance/pdf/aa302ins.pdf

SECTION A - COMPANY IDENTIFICATION

1. FID. NO. OR SOCIAL SECURITY 2. TYPE OF BUSINESS 3. TOTAL NO. EMPLOYEES IN THE ENTIRE

1. MFG 2. SERVICE 3. WHOLESALE COMPANY

4. RETAIL 5. OTHER

4. COMPANY NAME

5. STREET CITY COUNTY STATE ZIP CODE

6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE) CITY STATE ZIP CODE

7. CHECK ONE: IS THE COMPANY: SINGLE-ESTABLISHMENT EMPLOYER MULTI-ESTABLISHMENT EMPLOYER

8. IF MULTI-ESTABLISHMENT EMPLOYER, STATE THE NUMBER OF ESTABLISHMENTS IN NJ

9. TOTAL NUMBER OF EMPLOYEES AT ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT

10. PUBLIC AGENCY AWARDING CONTRACT

CITY COUNTY STATE ZIP CODE

Official Use Only DATE RECEIVED INAUG.DATE ASSIGNED CERTIFICATION NUMBER

SECTION B - EMPLOYMENT DATA

11. Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns. Where there are no employees in a particular category, enter a zero. Include ALL employees, not just those in minority/non-minority categories, in columns 1, 2, & 3. DO NOT SUBMIT

AN EEO-1 REPORT.

ALL EMPLOYEES PERMANENT MINORITY/NON-MINORITY EMPLOYEE BREAKDOWN

JOB COL. 1 COL. 2 COL. 3 ********* MALE************************************FEMALE**********************

CATEGORIES TOTAL MALE FEMALE AMER. NON AMER. NON

(Cols.2 &3) BLACK HISPANIC INDIAN ASIAN MIN. BLACK HISPANIC INDIAN ASIAN MIN.

Officials/ Managers

Professionals

Technicians

Sales Workers

Office & Clerical

Craftworkers (Skilled)

Operatives (Semi-skilled)

Laborers (Unskilled)

Service Workers

TOTAL

Total employment From previous Report (if any) Temporary & Part- Time Employees

12. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED? 14. IS THIS THE FIRST 15. IF NO, DATE LAST

1. Visual Survey 2. Employment Record 3. Other (Specify) Employee Information REPORT SUBMITTED

Report Submitted?

13. DATES OF PAYROLL PERIOD USED

From: To: 1. YES 2. NO

MO. DAY YEAR

SECTION C - SIGNATURE AND IDENTIFICATION

16. NAME OF PERSON COMPLETING FORM (Print or Type) SIGNATURE TITLE DATE

MO DAY YEAR

17. ADDRESS NO. & STREET CITY COUNTY STATE ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)

The data below shall NOT be included in the figures for the appropriate categories above.

Form AA- 302 Treasury D:20000727094525- 04'00' D:20000727094709- 04'00' Form AA302 Rev. 11/11

STATE OF NEW JERSEY

Division of Purchase & Property Contract Compliance Audit Unit EEO Monitoring Program

EMPLOYEE INFORMATION REPORT

IMPORTANT-READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING FORM. FAILURE TO PROPERLY COMPLETE THE ENTIRE FORM AND TO SUBMIT THE REQUIRED $150.00 FEE MAY DELAY ISSUANCE OF YOUR CERTIFICATE. DO NOT SUBMIT EEO-1 REPORT FOR SECTION B, ITEM 11. For Instructions on completing the form, go to: http://www.state.nj.us/treasury/contract_compliance/pdf/aa302ins.pdf

SECTION A - COMPANY IDENTIFICATION

1. FID. NO. OR SOCIAL SECURITY

2. TYPE OF BUSINESS

3. TOTAL NO. EMPLOYEES IN THE ENTIRE

1. MFG

2. SERVICE

3. WHOLESALE

COMPANY

4. RETAIL 5. OTHER

4. COMPANY NAME

5. STREET

CITY

COUNTY

STATE

ZIP CODE

6. NAME OF PARENT OR AFFILIATED COMPANY (IF NONE, SO INDICATE)

CITY

STATE

ZIP CODE

7. CHECK ONE: IS THE COMPANY:

SINGLE-ESTABLISHMENT EMPLOYER

MULTI-ESTABLISHMENT EMPLOYER

8. IF MULTI-ESTABLISHMENT EMPLOYER, STATE THE NUMBER OF ESTABLISHMENTS IN NJ

9. TOTAL NUMBER OF EMPLOYEES AT ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT

10. PUBLIC AGENCY AWARDING CONTRACT

CITY

COUNTY

STATE

ZIP CODE

Official Use Only

DATE RECEIVED

INAUG.DATE

ASSIGNED CERTIFICATION NUMBER

SECTION B - EMPLOYMENT DATA

11. Report all permanent, temporary and part-time employees ON YOUR OWN PAYROLL. Enter the appropriate figures on all lines and in all columns. Where there are no employees in a particular category, enter a zero. Include ALL employees, not just those in minority/non-minority categories, in columns 1, 2, & 3. DO NOT SUBMIT

AN EEO-1 REPORT.

ALL EMPLOYEES

PERMANENT MINORITY/NON-MINORITY EMPLOYEE BREAKDOWN

JOB COL. 1

COL. 2 COL. 3 ********* MALE************************************FEMALE**********************

CATEGORIES TOTAL MALE FEMALE

AMER.

NON

AMER. NON

(Cols.2 &3)

BLACK HISPANIC INDIAN ASIAN MIN. BLACK HISPANIC INDIAN ASIAN MIN.

Officials/ Managers Professionals Technicians Sales Workers Office & Clerical Craftworkers (Skilled) Operatives (Semi-skilled) Laborers (Unskilled) Service Workers

TOTAL

Total employment From previous Report (if any) Temporary & Part- Time Employees

12. HOW WAS INFORMATION AS TO RACE OR ETHNIC GROUP IN SECTION B OBTAINED? 14. IS THIS THE FIRST

15. IF NO, DATE LAST

1. Visual Survey 2. Employment Record 3. Other (Specify) Employee Information

REPORT SUBMITTED

Report Submitted?

13. DATES OF PAYROLL PERIOD USED

From:

To:

1. YES

2. NO

MO. DAY YEAR

SECTION C - SIGNATURE AND IDENTIFICATION

16. NAME OF PERSON COMPLETING FORM (Print or Type)

SIGNATURE

TITLE

DATE

MO DAY YEAR

17. ADDRESS NO. & STREET

CITY

COUNTY

STATE

ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)

The data below shall NOT be included in the figures for the appropriate categories above.