Indiana United Methodist Children's Home, Inc.


Application for Employment
 515 W. Camp Street - PO Box 747
Lebanon, Indiana 46052
Phone 765-482-5900 Fax 765-482-5942 e-mail iumch@iumch.org


To Applicant: Indiana United Methodist Children's Home, Inc. is an Equal Opportunity Employer. Applicants are considered for employment without regard to race, color, national origin, religion, sex, age, handicap, disability, or any other basis prohibited by law unless such basis constitutes a bonafide occupational qualification. Indiana United Methodist Children's Home, Inc. will comply with its legal obligation to provide reasonable accommodation to qualified individuals with disabilities.


The information contained in this application is valid for a period of six months. After that time, a new application may be required.


Last Name:
 First Name:
 Middle Initial:
Address: 
City:
 State:
 Zip Code:
Phone:  SS#:  Date: Sunday Aug 1, 2010


Position(s) Applied For:

How did you learn about us?
Advertisement Employment Agency Friend
Relative Walk-In Other

If your application is considered favorably, on what date could you start? 
Are you 21 years of age or older?   Yes   No
Are you available to work?   Full-Time   Part-Time
List days and times you are not available to work:
Are you on a lay-off from another company and subject to recall?   Yes   No
Have you filed an application here before?   Yes   No
If yes, give date(s):

Have you ever been convicted or pled guilty to a felony or misdemeanor (not minor traffic violations?   Yes   No
If yes, please explain:


Do you have a valid driver's license?   Yes   No

Record of Education
School Name & Location
Of School		 Courses of
Study		 Last Year
Completed		 Did You
Graduate		 List Degree
Or Diploma
HIGH  1 2
 3 4		 Yes
No
COLLEGE  1 2
 3 4		 Yes
No
 1 2
 3 4		 Yes
No
 1 2
 3 4		 Yes
No

Military Service Record
(If Applicable)
Were you in the Armed Service?   Yes  No    If yes, what branch?  
Dates of Duty: From to    Rank at Discharge: 
Discharge States:   Honorable   General   Dishonorable

List duties in the service including special training:


Have you taken any training under the G.I. Bill of Rights? Yes  No
If yes, what training did you take?


Personal References
(List Three References - Do not include relatives)
Name: Phone:
Occu.: EMail:
Name: Phone:
Occu.: EMail:
Name: Phone:
Occu.: EMail:

Please comment on skills and/or qualifications you feel would be pertinent to the position for which you have applied:

Employment Record

List below present and past employment, beginning with your most recent, for the past five years:


Job #1
Company: Employment Dates Describe Duties
From:  
To:  
Salary or Hourly Rate
Phone:  Start Pay: $ Job Title
Final Pay: $

Job #2
Company: Employment Dates Describe Duties
From:  
To:  
Salary or Hourly Rate
Phone:  Start Pay: $ Job Title
Final Pay: $

Job #3
Company: Employment Dates Describe Duties
From:  
To:  
Salary or Hourly Rate
Phone:  Start Pay: $ Job Title
Final Pay: $

Job #4
Company: Employment Dates Describe Duties
From:  
To:  
Salary or Hourly Rate
Phone:  Start Pay: $ Job Title
Final Pay: $

Job #5
Company: Employment Dates Describe Duties
From:  
To:  
Salary or Hourly Rate
Phone:  Start Pay: $ Job Title
Final Pay: $
Have you ever worked for any of the above employers or for any other company under a different name? Yes  No
If yes, please give the name:
Have you ever been discharged or asked to resign from any position? Yes  No
If yes, please state the employer and dates of employment:

Applicant's Statement
(Please indicate you have read and understand each paragraph of the Applicant's Statement by initialing beside each section and providing your name/signature at the bottom of this page.)

 I certify that all entries and information on this application are true and complete to the best of my knowledge. In the event of employment, I understand false, misleading or omitted information on my application may result in termination.
 I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This inquiry may include information as to my character and general reputation as well as my work performance and workplace conduct. I acknowledge as a condition of beginning employment I will be required to complete and sign a standard criminal history affidavit which will be checked and verified through law enforcement agencies.
 I authorize Indiana United Methodist Children's Home to verify my address and social security number as well as submitting my name for a national criminal history check and a check of the nationwide sex offender registry.
 I release Indiana United Methodist Children's Home, Inc., personal reference and previous employers from any liability for injury or damage that may result from information furnished to Indiana United Methodist Children's Home, concerning me or any action Indiana United Methodist Children's Home, Inc. takes on the basis of such information.
 I understand if offered a job at Indiana United Methodist Children's Home, Inc. that as a condition of beginning employment, I will be required to undergo a physical examination by the Agency's physician and to submit to a drug/alcohol screen.
 I understand according to federal law, all individuals who are hired must, as a condition of continued employment, produce certain documentation to verify their identity and United States citizen status or as aliens, their legal authorization to work in the United States. In addition, I understand an offer of employment is contingent upon my ability to produce the required documentation within the time frame specified by law.
 I understand this application is not a contract of employment and any employment relationship with this organization is of an "at will" nature, which means the employee may resign at any time and the employer may terminate the employee at any time with or without cause.

Name of Applicant: