New Account Application
___________________________________________
Street Address
Name________________________________________________
Mailing Address________________________________________
_____________________________________________________
Telephone Number_______________________________________________
Alternative Number_______________________________________________
Please provide the following information so that The City of Barrett complies with Federal Law prohibiting discrimination on the basis of race, color, or national origin. You are not required to furnish this information, but are encourage to do so. This information will not be used in evaluating your request for service or to discrinimate against you in any way. However, if you choose not to furnish this information, we are required to note your race/color/national origin on the basis of visual observation or surname.
Racial Categories (check all that apply) Ethnic Categories (check all that apply)
_____American Indian or Alaskan Native _____Hispanic or Latino
_____Asian _____Not Hispanic or Latino
_____Black or African American
_____Native Hawaiian or Pacific Islander
_____White