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: