Employer Report Form {PC-1}

IDHR Employer Report Form (PC-1) To Apply Online, Visit our Vendor Online Registration Page State of Illinois Illinois Department of Human Rights Legal Division, Public Contracts Unit Make Payment ($75 Certified Check, Cashier's Check, or Money Order to: ILLINOIS DEPARTMENT OF HUMAN RIGHTS and mail to: IDHR - FISCAL UNIT 100 W. RANDOLPH ST - SUITE 10-100 CHIAGO, IL 60601 Instructions: This form is to be used by an entity to apply for an IDHR Eligibility number, or to renew a number. IDHR Eligibility Numbers expire five years after the date of issue, and may be renewed at that time for a $75 fee. The information is necessary to accomplish the statutory purpose set forth in 775 ILCS 5/1-101 et seq. Disclosure of this information is REQUIRED. Forms received with the employment data omitted will not be processed. The gathering and retention of employee race/ethnicity and gender data is permitted by state and federal law so long as such data are kept separate from other personnel information and are not used for the purpose of committing unlawful discrimination. For administrative details, review 44 Ill. Admin Code, Section 750.210(a). You must have an IDHR Eligibility Number if you company wants to be eligible to bid on state contracts and any one of the following applies: 1) your company employs 15 or more persons at the time of application for a public contract; 2) your company has employed 15 or more persons at any time during the 365 day period prior to the date of your applying for a public contract; 3) you are directed to file by a contracting agency of the State of Illinois, any political subdivision, or a municipal corporation. A form is deemed filed when it is received by IDHR Chicago office, PROPERLY completed, signed, and accompanied by a certified check, money order, or cashier's check for $75 payable to the Illinois Department of Human Rights. No personal checks, business checks, or credit card numbers will be accepted. Any form without an approved form of payment will be returned unprocessed. This form must be filed prior to bid opening. To apply for or renew an IDHR Number using a credit card, visit the Vendor On-Line Registration page. Please visit our website at www2.illinois.gov/dhr/publiccontracts for more information. Sexual Harassment Policy: NO company without a sexual harassment policy will be issued an IDHR number. If you organization has no policy, and would like a model for creating one, please visit: http://www2.illinois.gov/dhr/PublicContracts/Pages/Sexual_Harassment_Model_Policy.aspx Federal Employer Identification Number (FEIN) must be provided. If your entity has multiple locations that all have the same FEIN, you are only obligated to pay one fee ($75) to receive an IDHR number for any locations having the same FEIN and wishing to be eligible to bid on business with the State of Illinois. A copy of the following form must be filled out for EACH location applying to do business with the State. (IDHR EMPLOYER REPORT FORM 4/22/2015 Employer Report Form - Submit to IDHR with Payment Note: An Employer IDHR Eligibility Number Expires 5 years from the date of issue/renewal IDHR Employer Report Form (PC-1) To Apply Online, Visit our Vendor Online Registration Page State of Illinois Illinois Department of Human Rights Legal Division, Public Contracts Unit Make Payment ($75 Certified Check, Cashier's Check, or Money Order to: ILLINOIS DEPARTMENT OF HUMAN RIGHTS and mail to: IDHR - FISCAL UNIT 100 W. RANDOLPH ST - SUITE 10-100 CHIAGO, IL 60601 Renewing an IDHR Number. Applying for a new IDHR Number. Adding/Renewing a location to a new or existing IDHR Number. IDHR Number (If renewing or adding location): FEIN (required): Name of Applying Company: Address: City: State: ZIP: County: Country: Contact Name: Contact Phone: E-mail: Does the company have a current, written sexual harassment policy? Within the past three years, has the company been declared ineligible for any public contract based on a finding of employment discrimination? If yes, attach a separate sheet fully explaining the situation. Yes Yes No No In the chart below, enter the racial and gender breakdown of the employees of the company, or the branch/location of the company/organization applying to be eligible to bid on contracts for the State of Illinois. White Male Female Total Black Hispanic Asian/Pacific Islander American Indian Totals I certify that the information provided in this report, and in any attachments thereto, is true and accurate to the best of my knowledge and belief. The employer filing this report agrees to conform with the requirements set forth in the Illinois Human Rights Act, 775 ILCS 5/1-101 et seq., and the rules and regulations of the Department of Human Rights. I am authorized to sign this form on behalf of the employer. Signature Date Typed Name and Title (IDHR EMPLOYER REPORT FORM 4/22/2015 Employer Report Form - Submit to IDHR with Payment Note: An Employer IDHR Eligibility Number Expires 5 years from the date of issue/renewal State of Illinois Illinois Department of Human Rights Legal Division, Public Contracts Unit Definitions, Clauses and Policies Applicable to the IDHR Employer Report Form Keep for your Records Definition of employee - For purposes of this form, an "employee" is an individual performing services for remuneration for the employer. All full-time and permanent part-time employees are to be reported. Forms received containing mathematic errors will not be processed. Description of Race/Ethnic - Race/ethnic designations as used by the Department do not denote scientific definitions of anthropological origins. For the purposes of this report, an employee may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be counted in more than one race/ethnic group. They are: "White (Not of Hispanic Origin)" All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. "Black or African-American" (Not of Hispanic Origin). All persons having origins in any of the Black racial groups of Africa. "Hispanic or Latino" All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. "Asian or Pacific Islander" All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. 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