1 Start 2 Preview 3 Complete Contact Information First Name * Last Name * E-Mail * Phone I wish to receive text updates Yes No Voluntary Demographic Information Form Date of Birth MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Year Have you served in the U.S. Armed Forces? (optional) Yes No Prefer not to disclose What branch of the military? Do you consider yourself to be Hispanic or Latino? The Equal Employment Opportunity Commission defines Hispanic or Latino as "a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race." You may also select Hispanic or Latino on the next question below if that is how you identify. Yes No Prefer not to disclose What is your race? Asian Black or African American Hispanic or Latino Native American or Alaska Native Native Hawaiian or Pacific Islander White Prefer not to disclose What is your gender identity? Female Male Non-binary/third gender Prefer not to disclose Broad Self-Identification as LGBTQ+ Yes No Prefer not to disclose Do you consider yourself a member of the Lesbian, Gay, Bisexual, Transgender, and/or Queer (LGBTQ) community? Do you live an Urban Area or a Rural Area? The Census Bureau identifies two types of urban areas: 1) Urbanized Areas of 50,000 or more people or 2) Urban Clusters of at least 2,500 and less than 50,000 people. “Rural” encompasses all population, housing, and territory not included within an urban area." Urban Area/Cluster Rural Prefer not to disclose Please select all boxes that apply regarding your religion (if any): Christian Jewish Muslim Buddhist Hindu Atheist Unitarian Universalist Other Prefer not to disclose Are you currently or have you ever been a member of a Labor union? Yes (Currently) Yes (Previously) No Prefer not to disclose Do you have (or have had) a disability? Yes No Prefer not to disclose Chapter Information State or Territory Unit * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming State Role - None -PresidentNational Committee RepresentativeLocal board leadershipMember National Role (optional) - None -Region ChairCaucus ChairAppointed Officer Preview
