The Equal Rights Center: Survey - Tester Pre-application Form

1.

Registration Information:


	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
	Street 1:
	Street 2:
	City:
	State / Province:
	ZIP / Postal Code:
	Country:
	Phone Number:
	Yes, I would like to receive e-mail from The Equal Rights Center
	Email Format:
	Yes, I would like to receive postal mail from The Equal Rights Center

Please enter a user name and password for logging in when you return. You can use this password to update your information or receive personalized content.

*	User Name: Required	5 to 60 characters
*	Password: Required	5 to 20 characters
*	Repeat Password: Required

*2.

Question - Required - Mobile Phone:

*3.

Question - Required - Date of Birth

Month

Day

Year

*4.

Question - Required - Sex:

*5.

Question - Required - National Origin:

6.

Question - Not Required - Do you speak any of the following languages? Please select any language that you speak, even if you speak the language at only a basic level.

	Amharic
	French
	Korean
	Mandarin
	Spanish
	Vietnamese
	Other

7.

Question - Not Required - If you selected "Other" in question 6, please specify the other language spoken.

*8.

Question - Required - Race/Ethnicity:

*9.

Question - Required - Employer:

*10.

Question - Required - Occupation:

11.

Question - Not Required - Spouse's Employer

*12.

Question - Required - Do you identify with a particular religion? (If you do, please write the name of the religion in the box below. If you do not, you may write "none.")

*13.

Question - Required - What is your sexual orientation?

	Heterosexual
	Homosexual
	Bisexual
	Other
	Choose not to disclose

*14.

Question - Required - Do you have a disability? Yes
No
Choose not to disclose

15.

Question - Not Required - If your answer to 13 was "yes," please describe your disability in 30 words or less. (Optional)

*16.

Question - Required - If your answer to 13 was "yes," will you need an accommodation to work as a tester? Yes
No
Choose not to disclose

17.

Question - Not Required - If your answer to question 15 was "yes," please briefly describe the accommodation that you will need. (Optional)

*18.

Question - Required - Civil rights testing and investigation involves posing as a particular type of individual during a business transaction in order to gather information about the kind of service you receive. Are you comfortable pretending to have certain financial and professional characteristics that are different from your own? Yes
No

*19.

Question - Required - Are you comfortable working with an organization involved in civil rights law enforcement? Yes
No

*20.

Question - Required - Have you ever experienced discrimination? Yes
No

*21.

Question - Required - Have you ever filed a complaint of discrimination with a local or federal agency, in state, federal, or county court, or with an employer? Yes
No

*22.

Question - Required - Would you be comfortable providing testimony under oath in situations where your credibility might be questioned? Yes
No

*23.

Question - Required - Have you ever engaged in "testing" or "auditing" for discrimination? Yes
No

*24.

Question - Required - If yes, for what agency or organization?

*25.

Question - Required - Do you presently work in housing, lending, or finance? Yes
No

*26.

Question - Required - Why do you want to be a tester?

*27.

Question - Required - When are you available for testing?
Please make between 1 and 14 selections from the choices below.

	Monday AM (8am-12)
	Monday Afternoon (12-5pm)
	Tuesday AM (8am-12)
	Tuesday Afternoon (12-5pm)
	Wednesday AM (8am-12)
	Wednesday Afternoon (12-5pm)
	Thursday AM (8am-12)
	Thursday Afternoon (12-5pm)
	Friday AM (8am-12)
	Friday Afternoon (12-5pm)
	Saturday AM (8am-12)
	Saturday Afternoon (12-5pm)
	Sunday AM (8am-12)
	Sunday Afternoon (12-5pm)

*28.

Question - Required - Do you have a car? Yes
No

*29.

Question - Required - Do you have a driver's license?" Yes
No

*30.

Question - Required - Have you ever been convicted of a felony? Yes
No

*31.

Question - Required - Have you ever been convicted of a crime involving fraud or perjury? Yes
No

*32.

Question - Required - Have you ever been dismissed from a job for misconduct involving dishonesty, fraud, theft? Yes
No

*33.

Question - Required - How did you hear about the ERC testing program? ERC Website
Idealist.org
Friend
Newspaper Ad
University Department
University Career Center
Student Organization
Government Agency
Library
Community Center
Church
Other

*34.

Question - Required - By submitting this form, I certify that the information contained herein is true. Signature

*35.

Question - Required - Date

Month

Day

Year