Free 48245.pdf - Indiana

MASTER JOB APPLICATION
State Form 48245 (R2 / 2-99) / IMP 0021

The information contained on this form is CONFIDENTIAL according to 470 IAC 1-2-7, 470 IAC 1-3-1, and 470 6-1-1.

PERSONAL INFORMATION
Citizen of the U.S? If No, are you legally allowed to work in the U.S.? Write your registration number here:

Yes
Date (month, day, year)

No

Yes

No

Social Security number

Name (last, first, middle)

Present address (number and street, city, state, ZIP code)

Permanent address (number and street, city, state, ZIP code)

Telephone number

Have you ever been convicted of a crime?

If Yes, explain in full (attach additional sheet if necessary)

Yes

No

Do you have a driver's license?

If Yes, what type?

Yes
Position:

No

Operator

Commercial

Chauffeur
Date you can start: Salary desired:

EMPLOYMENT DESIRED

Are you employed now?

If so, may we inquire of your present employer? When?

Ever applied to this company before?

Where?

Do you want to work:

Full-time

Part-time EDUCATION DID YOU CIRCLE LAST YEAR COMPLETED GRADUATE? 1 5 2 6 3 7 4 8 Yes No Yes No Yes No Yes No SUBJECTS STUDIED AND DEGREE(S) GIVEN

TYPE OF SCHOOL ELEMENTARY/ MIDDLE SCHOOL HIGH SCHOOL COLLEGE TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

NAME AND LOCATION OF SCHOOL

9 10 11 12 1 1 2 2 3 3 4 4

Special Study, Research, Foreign Language or other Skills:

PHYSICAL RECORD (Do you have any physical condition which may limit your ability to perform the job applied fo This question is voluntary, and any answers will be kept confidential.

FORMER EMPLOYERS (List below last four employers, starting with last one first) Date From Salary From Salary From Salary From Salary MILITARY SERVICE
Branch of service Period of active duty Rank of discharge

Name and Address of Employer

Describe Duties

Type of Machines or Equipment Used

Reason for

From
Describe duties:

To

ORGANIZATIONS AND VOLUNTEER ACTIVITIES (List responsibilites and offices)

Name

REFERENCES (Give below the names of three persons not related to you, whom you have known at least one year) Address Telephone Number Business Years Acquainted

IN CASE OF EMERGENCY NOTIFY:
Name Address Telephone number

I authorize investigation of all statements contained in this application. I understand that misrepresentation of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.
Date Signature