| Position applying for |
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| Legal First Name |
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| Legal Last Name |
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| Middle Name |
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| Maiden Name |
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| Address |
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| City |
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| State |
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| Zip code |
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| Phone number |
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| Alternate phone number |
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| E-mail address |
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| Best time to call you is: |
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| How did you find out about our job opportunities? |
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| Have you ever filed an application with the Easterseals Rehabilitation Center or one of its affiliates (Milestones, Community Living Services, Residential Services, Easterseals Posey County)? |
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| If yes, give date(s) and affiliate name |
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| Have you ever been employed with the Easterseals Rehabilitation Center or one of its affiliates? |
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| If yes, give date(s) and affiliate name |
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| Do any of your friends or relatives work for the Easterseals Rehabilitation Center or one of its affiliates? |
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| If yes, state name, relationship, and location |
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| If you are under 18 years of age, can you provide required proof of your eligibility to work? |
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| Are you legally eligible to work in the United States? (Proof of citizenship or immigration status will be required upon employment.) |
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| Have you ever been convicted of a criminal offense, which means pled guilty, had a judicial finding of guilt, or pled no contest that has not been expunged/erased by a court? |
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| Have you ever been convicted of a felony or misdemeanor that has not been expunged/erased by a court? (Conviction is not an automatic denial to employment.) |
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| Are there any pending charges against you? |
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| If you answered 'yes' to any of the above 3 questions, please provide details including nature of the crime, dates, and location. |
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| Are you currently employed? |
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| May we contact your present employer? |
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| Date available for work |
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| Are you available to work |
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| Days/times available |
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| Are you currently on "lay-off" status and subject to recall? |
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EDUCATION
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| High School |
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| High school address |
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| Number of years completed |
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| Please indicate if you have a diploma or GED |
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| Undergraduate |
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| Name of college or university |
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| Address of college/university |
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| Course of study |
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| Number of years completed |
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| Please indicate type of degree |
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| Graduate/Professional |
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| Name of university or professional school |
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| Address of university/professional school |
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| Course of study |
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| Number of years completed |
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| Please indicate type of degree |
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