Printable form
Indiana University is an Equal Opportunity/Affirmative Action Employer.
Name:
Address: City - Zip: State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Not USA or Canada Country:
Phone:
Email:
*Are you over 18 years of age? yes no
If required for the position, do you hold a valid driver's license? yes no
*Are you legally authorized to work in the United States? yes no
Are you a current Indiana University employee? yes no
If yes, date started, position, and location:
*Have you ever been employed by Indiana University in the past? yes no
If yes, your name (if different), date started and left, position, and location:
*Have you ever been convicted of a crime other than a minor traffic violation? yes no Convicted means you were declared guilty by a judge or you pleaded guilty in court. A conviction may have even taken place if you did not pay a fine or spend time in jail or in prison. A conviction could have been for either a misdemeanor or a felony. For IU purposes, driving while under the influence, driving on a suspended license, reckless driving, leaving the scene of an accident, and vehicular homicide are not minor traffic violations and must be declared (whether the result is a ticket or a more severe penalty). Minor traffic violations that result in tickets do not need to be declared. A criminal history investigation is done on each new employee, and employment with the University is conditional, subject to the findings of a criminal history investigation. Answering yes to this question does not automatically disqualify you for employment; however, information obtained from the investigation will be used in the employment review process.
If yes, you must disclose for each offense: date, charge, city, state and disposition: (Include type of offense (e.g., misdemeanor, felony) and judgement (e.g., guilty, conditional dismissal).)
What type of work will you accept?
*Work History: List your work history for at least the past seven years. Begin with the most recent position.
#1
From: To:
Name of Firm:
Address:
Supervisor:
Duties Involved:
Salary: Reason for Leaving:
#2
#3
#4
#5
Special Skills
Special skills/foreign languages/certifications/licenses:
Special equipment/computer hardware or software/industrial machinery/video or teleconferencing:
Indiana University is an Equal Opportunity/Equal Access/Affirmative Action institution. IU intends to maintain an alcohol and drug-free workplace and to comply with the Drug Free Workplace Act of 1988 and its amendments. To that end, all employees must comply with the University’s Substance Free Workplace policy. Annual security and fire safety reports containing policy statements and crime and fire statistics for Indiana University campuses are available at protect.iu.edu/police/crimestats/.
Please read and sign the following statement:
I certify that all information provided in all my application material is true. I understand that any false statement made herein is sufficient reason for rejection of this application or termination of subsequent employment regardless of date of discovery. I authorize the university to investigate all statements made in my application material for employment. I authorize such educational institutions and employers and others (and their agents or employees) to respond to questions concerning information given in this application material and I further release from liability such former employers, institutions, or persons providing such information to the university.
I understand that an offer of employment from Indiana University will be contingent on the receipt and evaluation of the background check report. Disclosure of convictions within this application does not automatically diqualify me for employment; however, information obtained from the investigation will be used in the employment review process.
I agree that the university may require my participation in and contribution to retirement programs while employed. I also understand that the direct deposit of my paycheck to my personal checking or savings account is a condition of employment. I understand that no offer of benefits such as a pension plan, insurance, vacation, or salary rate is final until cleared by Human Resources, and fully approved by appropriate university officials.
I have carefully read and understand this statement and, by my signature below, note such.
*Signature:______________________________________________ *Date: _________________
By signing you signify that all the information you have provided is true and that you have read and understand the Applicant's Statement.
All questions and statements must be answered in full or your application will not be processed.
