New Employee Application Form - Indiana

Employment Application Form
Indiana University is an Equal Opportunity/Armative Action Employer.
Have you ever been convicted of a criminal oense that has not been expunged, restricted,
or sealed by a judge?
r yes r 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 ne or spend time in jail or in prison. A conviction could have
been for either a misdemeanor or a felony. Certain trac oenses rise to the level of a misdemeanor
or felony and must be declared; examples include driving under the inuence, 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, sub-
ject to the ndings of a criminal history investigation. Answering yes to this question does not auto-
matically disqualify you for employment; however, information obtained from the investigation will be
used in the employment review process.
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 sucient 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
I understand that an oer 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 oer of benets such as
a pension plan, insurance, vacation, or salary rate is nal until cleared by
Human Resources, and fully approved by appropriate university ocials.
I have carefully read and understand this statement and, by my written or
electronic signature below, note such.
Indiana University is an Equal Opportunity/Equal Access/Armative 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 Universitys Substance
Free Workplace policy. Annual security and re safety reports containing
policy statements and crime and re statistics for Indiana University
campuses are available at
Name (print)
(Last) (First) (Middle)
Are you over 18 years of age? r yes r no
If required for the position,
do you hold a valid drivers license? r yes r no
Are you legally authorized to work in the United States? r yes r no
Are you a current Indiana University employee? r yes r no
If yes, date started, position, and location
Have you ever been employed by Indiana University in the past? r yes r no
If yes, your name (if dierent), date started and left, position, and location
If yes, you must disclose for each oense: date, charge, city, state and disposition:
(Include type of oense (e.g., misdemeanor, felony) and judgment (e.g., guilty, conditional dismissal).)
UHRS 7/2013
All questions and statements must be answered in full or your application will not be processed.
(Signature of Applicant) (Date)
Page 1/2
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