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2. The Civil Rights Act of 1964 and related nondiscrimination authorities require the City of Minot to ensure everyone has the opportunity to comment on the activities that may affect their community.

   To help with that, we ask that you respond to the following questions. Any information provided to The City will be retained solely for the purpose of collecting statistical data to ensure inclusion of all segments of the population affected by transportation programs and activities.

4. Sex

   1. Male
   2. Female
   3. Other
6. If Sex selected is Other:
8. Age Range

   1. 25 and younger
   2. 26-40
   3. 41-54
   4. 55 and older
10. Disability

    1. Yes
    2. No
12. Do you receive public assistance?

    1. Yes
    2. No
14. Race(s):

    1. Native American/American Indian
    2. Alaskan Native
    3. Asian
    4. Black/African American
    5. Hispanic/Latino
    6. Native Hawaiian/Other Pacific Islander
    7. White
    8. Other
16. If Race(s) selected is Other:
18. Language(s) most frequently spoken in your home:

    1. Arabic (العربية)
    2. English
    3. French (Française)
    4. German (Deutsch)
    5. Japanese (日本語)
    6. Portuguese (Portugues)
    7. Russian (Pусский)
    8. Spanish (Española)
    9. Other
20. If Language(s) selected is Other
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

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