Hr Form - 102
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1HR FORM – 102
SYNERGY SELF-IDENTIFICATION FORM FOR APPLICANT FLOW DATA
Completion of this sheet is voluntary and is not a requirement for employment.
APPLICANT
Name:
Date:
Position Applied for:
Gender:
Male:
Female:
It is the policy of Synergy Solutions to provide equal employment opportunity to all employees and applicants for
employment without regard to gender, race, color, religion, sexual orientation, national origin, age, disability, or
disabled or Vietnam-Era veterans’ status.
VARIOUS AGENCIES OF THE UNITED STATES GOVERNMENT REQUIRE EMPLOYERS TO COLLECT
INFORMATION ON APPLICANTS. INFORMATION REQUESTED ON THIS SHEET IS FOR PURPOSES OF
COMPLIANCE WITH THESE RECORDKEEPING REQUIREMENTS AND, TO DETERMINE RECRUITING AND
EMPLOYMENT PATTERNS.
If you wish to be identified, please provide any of the information requested on this form that you would like to
submit. You may submit this information now or at any time in the future. Such information will in no way affect the
decision regarding your application for employment. This sheet will be kept confidential and maintained separately
from your application form.
ETHNICITY/RACE
American Indian or Alaskan Native:
White
Please check
(Persons having origins in any of the original
(People having origins in any of the original
one box only
peoples of North, Central and South America,
people of Europe, Middle East, or Africa.)
and who maintain tribal affiliation or
Community attachment.)
Asian
Black or African American
(Persons having origins in any of the original
(Persons having origins in any of the black
peoples of the Far East, Southeast Asia or
racial groups of Africa.)
the Indian Subcontinent including, [e.g.,
Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands,
Thailand, and Vietnam])
Hispanic or Latino
Two or More Races
(Persons of Cuban, Mexican, Puerto Rico,
(Persons who identify with more than one of
South or Central American or other Spanish
the above races.)
culture.)
Native Hawaiian or Other Pacific Islander
Do Not Want To Disclose
(Persons having origins in any of the peoples
of Hawaii, Guam, Samoa or other Pacific
Islands.)
Please return this form with your completed Employment Application to the Human Resources Representative or to the facility
where you submitted your employment application. Thank you.
Form HR-102 (06/2014)
Company Proprietary
1
Distribution Prohibited without Prior Authorization
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