If you are interested please fax your application to: 317-248-9190 or send it via e-mail to Tammy: ighaus@comcast.net

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

Name:

Present Address:

Permanent Address:

Phone Number:

EDUCATION

Years            Date                 Subjects

Name and Location of  School        Attended*     Graduated*        Studied

Grammar School

High School

College

Trade, Business,

or Correspondence School

*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

GENERAL

Subjects of special study or research work

What foreign languages do you speak fluently?

Read?

Write?

U.S. Military or Naval service?

Rank?

Present membership in the National Guard or Reserves?

PHYSICAL RECORD

Do you have any physical defects that preclude you from performing any work for which you are being considered?

Were you ever injured?

Give Details:

Have you any defects in hearing?

In vision?

In speech?

In cases of emergency notify:

Name

Address

Phone number

FORMER EMPLOYERS

List below last four employers, starting with last one first

Date,                                          Name and Address                                                                         Reason for

Month and Year                         of Employer                         Salary                     Position              Leaving

1.

2.

3.

4.

REFERENCES

Give below the names and addresses of three persons, not related to you, whom you have known at least one year.

Years

Name                                        Address                                    Business                            Known

1.

2.

3.

I authorize investigation of all statements contained in the application.  I understand that misrepresentation or omission 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__________________________________________________