____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
IUHR 09/2018
EMPLOYMENT APPLICATION FORM
Indiana University is an Equal Opportunity/Afrmative Action Employer
Name (print): _______________________________________________________________________________________________________________________________________________________________________
(Last) (First) (Middle)
Are you over 18 years of age? q Ye s q No
If required for the position, do you hold a valid driver’s license? q Ye s q No
Are you legally authorized to work in the United States? q Ye s q No
Are you a current Indiana University employee? q Ye s q No
If yes, date started, position, and location: ____________________________________________
Have you ever been employed by Indiana University in the past? q Ye s q No
If yes, your name (if different), date started and left, position, and location: _____________
Have you ever been convicted of a criminal offense that has not been expunged, restricted,
or sealed by a judge?
q Ye s q 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. Certain traffic offenses rise to the level of
a misdemeanor or felony and must be declared; examples include driving under the influence,
driving on a suspended license, reckless driving, leaving the scene of an accident, and vehicular
homicide. 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)).
Notice:
Indiana University is an Equal Opportunity/Equal Access/Armative 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. The Annual Security and Fire Safety Report, containing policy
statements, crime and re statistics for all Indiana University campuses, is available online at
https://protect.iu.edu/police-safety/annual-reports/index.html. You may also request a
physical copy by emailing IU Public Safety at iups@iu.edu, or by visiting IUPD.
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 sucient 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 oer 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 disqualify 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 oer of benets such as a pension plan, insurance, vacation,
or salary rate is nal until cleared by Human Resources, and fully approved by
appropriate university ocials. I have carefully read and understand this statement
and, by my written or electronic signature below, note such.
Signature of Applicant: ____________________________________________________________
Date: ___________________________________
All questions and statements must be answered in full or your application will not be processed.
click to sign
signature
click to edit
![]()
