Employment Application
Additional Info For Location: *
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify a representative of the Human Resources Department.

All money entries on the screen are to be just numbers. Please do not include dollar signs($) or other punctuation.
Applicant Information
Position(s) applied for:
(Required)
Location Preference:
(Required)

Check all that apply.
 Ferdinand, Indiana
 Cannelton, Indiana
 Leland, Mississippi
Type Employment Desired:
Full-Time
Part-Time
Seasonal
Full Name (first middle last):
(Required)
Address:
(Required)
City:
(Required)
State:
(Required)
Zip:
(Required)
Primary Phone:
(Required)
Secondary Phone:
E-Mail:
(Required)
Date Available (MM/DD/YYYY):
(Required)
Desired Salary:
(Required)
Desired Salary Per:
(Required)
Hour
Year
Month
Week
If under 18 can you furnish a work permit if required?
N/A
Yes
No
If no, please explain:
Are you a citizen of the United States?
Yes
No
If no, are you authorized to work in the US?
Yes
No
Have you ever worked for this company?
Yes
No
If yes, give dates and positions:
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accomodation)?
This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accomodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Have you ever been convicted of a felony?
Yes
No
If yes, explain:
Answering "Yes" to these questions does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Skills and Qualifications
Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:
Education
High School:
Address:
Years Completed:
Did you graduate?
Yes
No
Diploma
GED
Click for Post High School Education
College:
Address:
Years Completed:
Did you graduate?
Yes
No
Degree:
Click for Additional Education
Other:
Address:
Years Completed:
Did you graduate?
Yes
No
Degree:
References
List name and telephone number of business/work references who are not related to you and are not previous supervisors. If not applicable, list school or personal references who are not related to you.
Reference 1:
Full Name:
Relationship:
Company:
Phone:
Address:
Years Known:
less than 1 Yr.
1 Yr.
1-3 Yrs.
5 Yrs.
+5 Yrs.
Click for 2nd reference

Reference 2:
Full Name:
Relationship:
Company:
Phone:
Address:
Years Known:
less than 1 Yr.
1 Yr.
1-3 Yrs.
5 Yrs.
+5 Yrs.
Click for 3rd reference

Reference 3:
Full Name:
Relationship:
Company:
Phone:
Address:
Years Known:
less than 1 Yr.
1 Yr.
1-3 Yrs.
5 Yrs.
+5 Yrs.
Previous Employment
Starting with your most recent employer, provide the following information.
Company:
Phone:
Address:
Supervisor & Title:
Job Title:
From/To Dates:
-
Starting/Ending pay:
(Required when employer info entered)
-
Ending pay frequency:
Hour
Year
Month
Week
Summary of Nature of Work:
Reason for Leaving:
(Required when employer info entered)
May we contact your previous supervisor for a reference:
Yes
No
Click for prior employer information
Company:
Phone:
Address:
Supervisor & Title:
Job Title:
From/To Dates:
-
Starting/Ending pay:
(Required when employer info entered)
-
Ending pay frequency:
Hour
Year
Month
Week
Summary of Nature of Work:
Reason for Leaving:
(Required when employer info entered)
May we contact your previous supervisor for a reference:
Yes
No
Click for prior employer information
Company:
Phone:
Address:
Supervisor & Title:
Job Title:
From/To Dates:
-
Starting/Ending pay:
(Required when employer info entered)
-
Ending pay frequency:
Hour
Year
Month
Week
Summary of Nature of Work:
Reason for Leaving:
(Required when employer info entered)
May we contact your previous supervisor for a reference:
Yes
No
Military Information
Military Branch:
From/To Dates:
-
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature
Click to view applicant statement
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents, to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, résumé or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that 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 from consideration for employment on the basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment it will be necessary to reapply and 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 to contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any other protected status. The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and throughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) eliminate me from further consideration for employment, or (2) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNITL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Last 4 digits of your Social Security Number:
(Required)


Signature of Applicant:
(Required)


Attach Résumé: (Only .doc, .docx, .rtf, and .pdf files will be accepted.)
Security Question: What is 1 + 7?
(Required)