Human Relations 1010
Mock Application
TO APPLICANT: We appreciate your interest in our company and assure you that we are sincerely interested in your
qualifications. Your cooperation in providing a clear understanding of your background and work history will aid us in
considering you for a position that best meets your qualifications. It is important to be complete and accurate since the
information is used to determine who is interviewed and to determine starting pay. This company is an Equal Opportunity
Employer. None of the information disclosed on this application will be used by the company in an unlawful, discriminatory
manner or purpose. If you need an accommodation in order to complete the application process or take any required tests, such
assistance is available at the Company’s Human Resources Office upon request.
Date
Position desired
Recruitment # (if known)
Where did you hear about the position for which you have applied?
Desired hourly wage
or annual salary
On what date will you
be available to work?
$
PERSONAL INFORMATION
Name
Last
First
Middle
Address
Number
Street
City
State
Zip
E-Mail Address (optional)
Phone you can be contacted at, during Day (
)
Evening
Area Code
Have you ever worked under another name?
Yes
Are you at least 16 years of age?
No
Yes
Number
No
(
)
Area Code
Number
If “Yes” state name and place of employment.
Are you legally eligible for employment in this country?
Yes
No
(Proof of U.S. citizenship or immigration status will be required upon hiring, as required by the Immigration Reform
and Control Act of 1986.)
MILITARY SERVICE
Were you in the U.S. Armed Services?
Dates:
From
To
Yes
No
If “Yes,” list branch of service
Rank
List duties in service including special training applicable to desired position
EDUCATION INFORMATION
Educational Institution & Address
High
School
Credit
Hours
Subjects Studied

Graduated
Yes or No
Diploma/Degree
Received

College
College
Graduate
Work
Other
List academic honors, scholarships, etc., you consider significant and relevant to employment
Licenses and Certifications: List any professional licenses and certificates, such as Professional Engineer, Registered
Architect, Land Surveyor, Certified Public Accountant, Registered Nurse, etc. Please list license or certificate number
expiration date, and state where issued.
Computer knowledge/special skills
Other education or specialized training
List any professional and/or community organizations to which you belong. Any organization(s) which would indicate
your race, creed, color, gender, religion, national origin ancestry, sexual orientation, marital status, age, disability or other
protected status may be excluded.
EMPLOYMENT RECORD
Please describe your work interest or objective
List your employment history for the past 10-12 years starting with present or most recent employer. If more space is necessary,
include an additional sheet. Organizations which indicate race, creed, color, gender, religion, national origin ancestry, sexual
orientation, marital status, age, disability or other protected status may be excluded.
Dates
From
To
Mo/Yr Mo/Yr
Position Title/Duties
May we contact the employers listed?
wish us to contact.
Firm or Organization
Address, Telephone Number
Yes
Name and Position
of Supervisor
Reason for
leaving
Full
Time
Part
Time
No If “No,” please indicate which one(s) you do not
State your occupation during all periods not already covered by your employment history (include unemployment,
attending school, or self-employment.)
MISCELLANEOUS
List any relative (or member of your household) in our employ
Have you been convicted of a felony or misdemeanor offense more serious than a minor traffic violation?
NOTE: A conviction record is not an automatic bar to employment. Each situation is considered in relation to the position applied for.
Yes
No
If “Yes,” please explain
Date of Conviction
PROFESSIONAL REFERENCES
List four (4) persons who are not related to you and who have definite knowledge of your qualifications and
suitability for the position for which you are applying.
Name
Occupation/Position Title
Firm or Organization
Address and Telephone Number
Number of
Years Known
PLEASE READ CAREFULLY
I certify that the above statements are correct to the best of my ability. I understand that any false, misleading,
intentionally or omitted information on this application (or its supporting documents) may be sufficient
grounds for refusal to hire or termination without notice. I authorize the company to review my education,
previous employment, and other background information (where doing so is allowed by law) as may be
necessary in arriving at an employment decision. I hereby release all persons who provide any such
information to the company from any liability.
I hereby understand that (unless otherwise defined by applicable law) any employment relationship with this
organization is of an “at will” nature, which means the Employer may discharge the Employee at any time
with or without cause. I also understand (that as required by federal law) I will be required (if hired) to
furnish documentation establishing my identity, and eligibility to work in the United States.
DATE
SIGNATURE OF APPLICANT
Applications sent electronically will require signature if interviewed
NOTICE OF NONDISCRIMINATION- The company does not discriminate on the basis of race, creed, color, gender,
religion, national origin ancestry, sexual orientation, marital status, age, disability, status as a disabled veteran or
veteran of the Vietnam Era or other protected status. The company highly values diversity.
Revised 6/10