EMPLOYMENT APPLICATION

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APPLICANT INFORMATION

Instructions: Please ensure that you have all of the necessary information before beginning your application. You will not be able to go back and edit your application. Fields marked with a * indicate a required field. At least one previous employment is required.

First Name: *	Middle Initial:	Last Name: *
Street Address: *		Apartment/Unit #:
City: *	State: *	Zip: *
Phone Number: *	Email Address: *
Have you lived in any state other than Indiana during the past 3 years? *   Yes   No
Date Available:	Position Applied For:
Have you ever been placed on the OIG exclusions list? *  Yes   No		Have you ever been sued for medical malpractice? *  Yes   No
Are you a citizen of the United States? *  Yes   No		If no, are you authorized to work in the U.S.?   Yes   No
Have you ever worked for this company? *  Yes   No		If so, when?
Have you ever been convicted of a felony? *  Yes   No		If yes, explain?
Do you have a valid driver’s license? *  Yes   No		Do you have reliable transportation? *  Yes   No
Do you have auto insurance? *  Yes   No
Please list any alternate names you have used in the past.
When are you available to work? Days Evenings Weekends As needed
How did you hear about our company?

EDUCATION

High School: *		Address: *
From: *	To: *	Did you graduate? * Yes   No
College:		Address:
From:	To:	Degree:
Other:		Address:
From:	To:	Degree:

REFERENCES (Please list three professional references)

Reference #1
Full Name: *		Relationship: *
Company:		Phone: *
Address:
Reference #2
Full Name: *		Relationship: *
Company:		Phone: *
Address:
Reference #3
Full Name: *		Relationship: *
Company:		Phone: *
Address:

PREVIOUS EMPLOYMENT

Employee #1
Company: *		Phone: *
Address: *		Supervisor: *
Job Title: *	Starting Salary: *	Ending Salary: *
Responsibilities: *
From: *	To: *	Reason for Leaving: *
May we contact your previous supervisor for a reference? *  Yes   No
Employee #2
Company:		Phone:
Address:		Supervisor:
Job Title:	Starting Salary:	Ending Salary:
Responsibilities:
From:	To:	Reason for Leaving:
May we contact your previous supervisor for a reference?   Yes   No
Employee #3
Company:		Phone:
Address:		Supervisor:
Job Title:	Starting Salary:	Ending Salary:
Responsibilities:
From:	To:	Reason for Leaving:
May we contact your previous supervisor for a reference?   Yes   No

MILITARY SERVICE

Branch:	From:	To:
Rank at Discharge:		Type of Discharge:
If other than honorable, explain:

DISCLAIMER AND SIGNATURE

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancelation of this application or immediate discharge from the employer’s service, whenever it is discovered.I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other corporations or organizations for furnishing such information. The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant for consideration for employment on a basis prohibited by local, state or federal law. The application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

Initials *

Human Check

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