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?:
(Phone #)
(Cell #)
(Email address)
 
Applicant info:
(Age)
(Date of birth)
(City of birth)
List three apprenticeships that interest you:
1.   2.   3.
Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Do you own a car?
If you have no car, whose car will you use? Are you registered with Selective Service?
Are you a veteran? Total active duty (not including reserve time), if applicable:
From: To:
Do you have a valid Indiana driver's license? Do you have a valid CDL license?
Educational background
High school:
(Name of high school attended)
GED:
(GED)
(Scores available?)
(GED completion date)
College:
(Years attended)
(Other schools attended)
Have you taken and passed one (1) full year of high school algebra?
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?

Have you ever been convicted of a felony?

Have you ever been through this program before?

Who referred you to this program?

Name of source that referred you:
(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: