Apply for the Indiana Plan
Please check one:
INDIANAPOLIS OFFICE:
GARY OFFICE:
EVANSVILLE OFFICE:
Contact information
Full name:
(Last name)
(First name)
(M.I.)
Address:
(Street address)
(Last 6 of Social Security #)
(City)
(State)
(ZIP)
(County)
Contact:
Net access?:
--Select--
Yes
No
(Phone #)
(Cell #)
(Email address)
Applicant info:
(Age)
(Date of birth)
(City of birth)
List three apprenticeships that interest you:
1.
--Select--
Bricklayer
Carpenter
Cement mason
Electrician
Glazier
Heat and frost insulator
Ironworker
Laborer
Millwright
Operating engineer
Painter
Plumber and pipefitter
Roofer
Sheet metal worker
2.
--Select--
Bricklayer
Carpenter
Cement mason
Electrician
Glazier
Heat and frost insulator
Ironworker
Laborer
Millwright
Operating engineer
Painter
Plumber and pipefitter
Roofer
Sheet metal worker
3.
--Select--
Bricklayer
Carpenter
Cement mason
Electrician
Glazier
Heat and frost insulator
Ironworker
Laborer
Millwright
Operating engineer
Painter
Plumber and pipefitter
Roofer
Sheet metal worker
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
Do you own a car?
--Select--
Yes
No
--Select--
Yes
No
If you have
no
car, whose car will you use?
Are you registered with Selective Service?
--Select--
Yes
No
Are you a veteran?
Total active duty (not including reserve time), if applicable:
--Select--
Yes
No
From:
To:
Do you have a
valid
Indiana driver's license?
Do you have a valid CDL license?
--Select--
Yes
No
--Select--
Yes
No
Educational background
High school:
--Select--
None
9
10
11
12
Graduated
(Name of high school attended)
GED:
--Select--
Yes
No
--Select--
Yes
No
(GED)
(Scores available?)
(GED completion date)
College:
--Select--
None
1
2
3
4
More
Graduated
(Years attended)
(Other schools attended)
Have you taken and passed one (1) full year of high school algebra?
--Select--
Yes
No
Have you taken any of the following courses: (check all that apply)
Geometry
Trig.
Calculus
Physics
Other
Personal information
(
Confidential pursuant to: 20CFR (1977) Ch. 5Sec.604.16:IC22-44-19-6.IC4-6
)
Please complete this section for our records. Thank you.
Have you ever been arrested for a felony?
--Select--
Yes
No
Have you ever been convicted of a felony?
--Select--
Yes
No
Have you ever been through this program before?
--Select--
Yes
No
Who referred you to this program?
--Select--
None
Friend
Relative
Organization
Name of source that referred you:
--Select--
Yes
No
--Select--
Yes
No
--Select--
Yes
No
--Select--
Male
Female
(Height)
(Weight)
(Married)
(Single)
(Divorced)
(Gender)
Ethnicity:
African-American
Asian
White/Caucasian
Native American / Alaskan native
Hawaiian / Pacific Islander
Hispanic
Other
Did not identify
Previous employment
(beginning with the most recent)
Employer name:
Date of hire:
End date:
Monthly wage:
Reason for leaving:
Type of business:
Job title:
Employer name:
Date of hire:
End date:
Monthly wage:
Reason for leaving:
Type of business:
Job title:
Employer name:
Date of hire:
End date:
Monthly wage:
Reason for leaving:
Type of business:
Job title:
Other contacts information
Please list the names and addresses of two relatives and/or friends:
(Name)
(Address)
(Phone)
(Name)
(Address)
(Phone)
Submit application
I certify that my answers are true and complete to the best of my knowledge by checking this box: