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13 <br /> Voluntary Title VI Public Involvement <br /> Title VI of the Civil Rights Act of 1964 requires the North Carolina Department of Transportation (NC <br /> DOT) to gather statistical data regarding participants and beneficiaries of the agency's federal-aid <br /> programs and activities. NC DOT collects information on race, color, national origin and gender of the <br /> attendees to this public meeting to ensure the inclusion of all segments of the population impacted by a <br /> proposed project. <br /> NC DOT wishes to clarify that this information gathering process is completely voluntary and that you <br /> are not required to disclose the statistical data requested to participate in this meeting. This form is a <br /> public document used to collect data, only. <br /> The completed forms will be held on file at the North Carolina Department of Transportation. For Further <br /> information regarding this process please contact the NCDOT Title VI Program at telephone number <br /> 919.508.1808 or email at titlevikncdot.gov. <br /> Project Name: Date: <br /> Meeting Location: <br /> Name (please print) Gender: <br /> ❑ Male ❑ Female <br /> General ethnic identification cat e ories check one <br /> ❑ Caucasian I ❑ Hispanic American ❑ American Indian/Alaskan Native <br /> ❑ African American ❑ Asian/Pacific Islander Other: <br /> Color: National Origin: <br /> After completing this form,please fold and place it inside the designated box on the registration table. <br /> Thank you for your cooperation. <br />