Mid-City

Mid-City Application

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Position Applying For
Elkhart, Indiana South Bend, Indiana Plymouth, Indiana
Michigan City, Indiana Jenison, Michigan Warsaw, Indiana
Full Name
E-mail Address
Address                        
 
City   
Zip Code
Have you been a resident of any other states or counties in the last seven years?
      Yes       No
If Yes, please list:
         
Home Phone
(999-999-9999)
Cell Phone
(999-999-9999)
If you are less than 18 years of age, can you provide required proof of your eligiblity to work?
      Yes       No
Have you ever filed an application with us before?
      Yes       No
 If yes, please provide date    Year  
Do any of your friends or relatives other than your spouse work here?
 Yes       No
  If yes, please state relationship  
Do you have a valid drivers license ?
      Yes       No
If Yes, please list the type of license, license number and state of issuance:
         
Have you had any moving violations or suspensions in the last 7 years?
      Yes       No
If Yes, please list the type and date of offense(s):
         

Have you been convicted of a crime in the past 7 years?
      Yes       No
If Yes, please list incident, city/state of occurrence, and charges:
         

Are you currently employed?
      Yes       No
May we contact your present employer?
      Yes       No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?
      Yes       No
Date available for work? 
What is your desired salary?    
Are you available to work:
Full Time        Part Time    
Are you available to work:
Weekdays        Evenings       Weekends        Overtime    
Are you currently on "lay-off" status and subject to recall?
      Yes       No

Education
High School Name
High School Address
City   
Zip Code
Did you graduate?  Yes    No


College Name

City   
Zip Code
Did you graduate?  Yes    No
Majors/Degrees


Other   
Address
City   
Zip Code
Did you graduate?  Yes    No
Majors/Degrees

Qualifications

Please list any skills, licenses, or certifications that you feel would be of value to the job or the company
Skills
Licenses
Certifications


Work History
Please begin with your present or most recent job.
Employer
Address
City   
Zip Code
Telephone Number
Job Title
Supervisor Name
Employed from    /   to    /
Average weekly earnings:   
Reason for Leaving
May we contact this employer?       Yes       No


Employer

Address
City   
Zip Code
Telephone Number
Job Title
Supervisor Name
Employed from    /   to    /
Average weekly earnings:   
Reason for Leaving
May we contact this employer?       Yes       No


Employer

Address
City   
Zip Code
Telephone Number
Job Title
Supervisor Name
Employed from    /   to    /
Average weekly earnings:   
Reason for Leaving
May we contact this employer?       Yes       No


Personal and Professional References
(Please exclude family members)

Name
Telephone Number
(999-999-9999)
Best time to call   
Occupation
Relationship to Applicant


Name
Telephone Number
(999-999-9999)
Best time to call   
Occupation
Relationship to Applicant


Name
Telephone Number
(999-999-9999)
Best time to call   
Occupation
Relationship to Applicant


Please Read and Submit

This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination based on sex, marital status, race, color, age, creed, national origin, sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. 

Check boxes that apply:

  Applicant's Electronic Signature