Employment Application
We are an equal opportunity employer and always hire the best qualified individual for the job based upon job-related qualifications and regardless of race, color, creed,
sex, national origin, age, disability, or other protected group under state, federal, or local law.
Contact Information
First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
Email:
Zip Code:
Daytime Telephone
Number:
(
)
Personal Information
Are you at least 18 years of age?
Do you have a valid Indiana drivers license?
 Yes
 Yes
 No
 No
Do you have a legal right to work in the U.S.?
Are there times or days you cannot work?
 Yes
 Yes
 No
 No
Can you lift at least 75 pounds and work in
Will you work overtime if required?
extreme weather conditions?
 Yes
 Yes
 No
 No
Have you ever pled GUILTY, NO CONTEST, or been CONVICTED of a crime?
 Yes
 No
If yes, please explain.
Will you agree to pre-employment and random
Are you willing to be laid off during the winter months if
employee drug/alcohol screening?
necessary?
 Yes
 Yes
 No
 No
Educational History
Type Of
School
High School
Name of School
City &
State
Major
College
Circle Years
Completed
9 10 11 12
1
2
3
Military History
Military Branch
Dates Of Service
Title
Duties:
4
Type Of Degree
Earned
Grade Point
Average
Employment History
Employer’s Name:
Dates of Employment
Title
Hourly Wage Rate
Month
Year
From:
Reason Leaving:
To:
Name & Phone Number Of Immediate Supervisor:
(
)
How did you spend your time during your unemployment?
Street Address:
City:
State:
Dates of Unemployment
Month
From:
To:
Year
Employer’s Name:
Dates of Employment
Title
Hourly Wage Rate
Month
Year
From:
Reason Leaving:
To:
Name & Phone Number Of Immediate Supervisor:
(
)
How did you spend your time during your unemployment?
Street Address:
City:
State:
Dates of Unemployment
Month
From:
To:
Year
Employer’s Name:
Dates of Employment
Title
Hourly Wage Rate
Month
Year
From:
Reason Leaving:
To:
Name & Phone Number Of Immediate Supervisor:
(
)
How did you spend your time during your unemployment?
Street Address:
City:
State:
Dates of Unemployment
Month
From:
To:
Year
Please list any special skills you posses and/or training which you have received that would make you qualified
for the position for which you are applying.
I hereby certify that the information contained in this application is correct to the best of my knowledge. I understand that to
falsify, omit, or misrepresent information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person,
organization, or company listed on this application to furnish you any and all information concerning my previous employment and
education qualifications for employment. If hired, I agree to abide by the rules and regulations of the company, which rules may be
changed, withdrawn, added, or interpreted at any time, at the company’s sole option and without prior notice to me.
I have hereby read and understand the above statement and agree to its terms and conditions:
Signature:
Date: