CONTACT 812-376-8266 NOTE: This application form was designed for use by persons applying for operational associate positions. This application will be considered valid for 90 days after the date of application. Date of Application(Required) MM slash DD slash YYYY Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Phone Type Mobile Home Business Position DesiredPress Ctrl to select multiple positionsMachine OperatorWelderAssemblyPick/PackShippingMaterial HandlerPolisherOtherIf OtherHours Full Time Part Time Other Date Available MM slash DD slash YYYY Salary/Compensation DesiredReferral Source Employment Agency Newspaper Ad Walk-In Applicant School / College Employee Referral Other If OtherHave you ever applied for a position with us? Yes No If yes, when? MM slash DD slash YYYY Have you ever been employed by us? Yes No If yes, when? MM slash DD slash YYYY Do you have a relative working here? Yes No If yes, state relationshipAre you currently employed? Yes No Educational DataHigh SchoolHigh School NameAddress Street Address City State / Province / Region ZIP / Postal Code Years CompletedDegreeMajor Course Study CollegeCollege NameAddress Street Address City State / Province / Region ZIP / Postal Code Years CompletedDegreeMajor Course Study Trade/BusinessTrade/Business NameAddress Street Address City State / Province / Region ZIP / Postal Code Years CompletedDegreeMajor Course Study OtherOther NameAddress Street Address City State / Province / Region ZIP / Postal Code Years CompletedDegreeMajor Course StudyEmployment HistoryIn the following spaces give a complete record of your employment including periods of unemployment, if any. Begin with your most recent employment and work back.1st Employer NameAddress Street Address City State / Province / Region ZIP / Postal Code TelephoneStarting SalaryFinal SalaryImmediate SupervisorEmployed From MM slash DD slash YYYY To MM slash DD slash YYYY Starting PositionLast PositionOther PositionsDutiesReason for Leaving 2nd Employer NameAddress Street Address City State / Province / Region ZIP / Postal Code TelephoneStarting SalaryFinal SalaryImmediate SupervisorEmployed From MM slash DD slash YYYY To MM slash DD slash YYYY Starting PositionLast PositionOther PositionsReason for Leaving 3rd Employer NameAddress Street Address City State / Province / Region ZIP / Postal Code TelephoneStarting SalaryFinal SalaryImmediate SupervisorEmployed From MM slash DD slash YYYY To MM slash DD slash YYYY Starting PositionLast PositionOther PositionsDutiesReason for Leaving 4th Employer NameAddress Street Address City State / Province / Region ZIP / Postal Code TelephoneStarting SalaryFinal SalaryImmediate SupervisorEmployed From MM slash DD slash YYYY To MM slash DD slash YYYY Starting PositionLast PositionOther PositionsDutiesReason for LeavingAdditional Inquiries Concerning Employment HistoryMay we contact your present employer? Yes No Previous employers? Yes No Please identify any exceptions and reasons for not contacting.In order to permit a check of your work and education records, should we be made aware of any change of name or assumed name that you previously used? Yes No If “yes”, identify name(s) and relevant date(s).Have you ever been discharged or involuntarily forced to resign from any employment? Yes No If “yes”, please explain.Are you eligible for rehire from previous employers? Yes No Except for vacations and holidays, how many work days were you absent during the past calendar year? 0-5 days 5-10 days 10-15 day 15-20 days 20+ days During the prior year? 0-5 days 5-10 days 10-15 day 15-20 days 20+ days CommentsGeneral InformationIf employment is offered, can you submit a birth certificate, social security card, and certificate of U.S. Citizenship or verification of your legal right to work in the U.S.? Yes No If employment is offered, can you produce personal identification such as a U.S. passport, a driver’s license or photographic identification card issued by the State? Yes No Are you over 18 years of age? Yes No Have you ever been convicted of a felony? Yes No (An affirmative response will not automatically disqualify you from being considered as a candidate for employment.)If “yes”, please explain.If you are applying for a position involving evening or weekend work, can you fulfill such scheduling requirements? Yes No Not applicable Are you willing to work overtime as requested? Yes No Not applicable Please Read Each Statement Carefully Before SigningI certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand I may be required to successfully pass a drug screening examination as well as a job related post offer physical abilities assessment. I hereby consent to a pre-and/or post employment hair follicle test and a post offer job related physical abilities assessment test as a condition of being hired. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME, IF EMPLOYED. I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I have read, understand, and by my signature consent to these statements.Electronic Signature(Required)Date(Required) MM slash DD slash YYYY Δ
