IMMI
18881 U.S. 31 North
Westfield, IN 46074
Application For Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

* PLEASE NOTE A FIELD HIGHLIGHTED IN RED MEANS THERE IS AN ERROR WITH THE INFORMATION ENTERED. PLEASE REVIEW ANY RED FIELDS AND CORRECT ANY ERRORS.

     
First Name Social Security Number
Last Name
Address
City State Zip A value is required.
Phone A value is required. Mobile Email Address A value is required.
Position(s) Applied For Date of Application (mm/dd/yyyy) A value is required.
   
Referral Source
Walk In School
Employee Job Fair
Advertisement Staffing Agent
Company Website Gov't Employment Agency
Other Internet Other
     
If necessary, best time to call you at home is Will you work overtime if required?
May we contact you at work?
If yes, work number and best time to call:

 If No, Please Explain:
If you are under 18 and it is required, can you furnish a work permit?

If No, Please Explain:

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a Disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Have you submitted an application here before?

If Yes, give date(s) and position(s):

Driver's License required if driving may be required for the job in which you are applying.

Number
State

Have you ever been employed here before?
If Yes, give date(s) and position(s):
 Have you ever been bonded? Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Are you legally eligible for employment in this country?

Have you ever pleaded "guilty" or "no contest" to, or been convicted of a crime?
If Yes, please provide date(s) and details:

Date available for work:

(MM/DD/YY)

What is your desired salary range or hourly rate of pay?

$ Per A value is required.

Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?


If Yes, please explain):
Type of employment desired: Full Part-Time
Educational Co-Op Seasonal Temporary 		 
Will you relocate if job requires it? Yes No  
Will you travel if job requires it? Yes No  

If they have been explained to you, are you able to meet with attendance requirements of the position?
N/A Yes No

  
Employment History
Starting with your most recent employer, provide the following information:
Employer Telephone # ( )
Street Address: City: State:
Starting job title/final job title:
Immediate supervisor and title (most recent position held)
May we contact for reference? Yes No Later
Why did you leave?
Dates employed: A value is required. (MM/DD/YY)
Compenstation (Starting)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Compenstation (Final)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What were the things you liked least about the position?
 
Starting with your most recent employer, provide the following information:
Employer Telephone # ( )
Street Address: City: State:
Starting job title/final job title:
Immediate supervisor and title (most recent position held)
May we contact for reference? Yes No Later
Why did you leave?
Dates employed: (MM/DD/YY)
Compenstation (Starting)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Compenstation (Final)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What were the things you liked least about the position?
 
Starting with your most recent employer, provide the following information:
Employer Telephone # ( )
Street Address: City: State:
Starting job title/final job title:
Immediate supervisor and title (most recent position held)
May we contact for reference? Yes No Later
Why did you leave?
Dates employed: (MM/DD/YY)
Compenstation (Starting)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Compenstation (Final)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What were the things you liked least about the position?
 
Starting with your most recent employer, provide the following information:
Employer Telephone # ( )
Street Address: City: State:
Starting job title/final job title:
Immediate supervisor and title (most recent position held)
May we contact for reference? Yes No Later
Why did you leave?
Dates employed: (MM/DD/YY)
Compenstation (Starting)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Compenstation (Final)
Hourly Salary
$ Per
Commission/Bonus/Other Compensation:
$
Summarize the type of work performed and job responsibilities:
What did you like most about your position?
What were the things you liked least about the position?
Employment History
Explain any gaps in your employment, other than those due to personal illness, injury or disability.
If not addressed on previous page, have you ever been fired or asked to resign from a job?
If yes, please explain:
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:
Word Processing
Spreadsheet
Presentation
E-Mail

Years
Years
Years
Years 		Internet
Other
Other
Other 		Years
Years
Years
Years
Educational Background
Starting with your most recent school attended, provide the following information

School (Include City and State)

Years Completed

Completed

GPA
Class Rank

Major/Minor
Diploma GED
Degree
Certification
Other
Diploma GED
Degree
Certification
Other
Diploma GED
Degree
Certification
Other
Diploma GED
Degree
Certification
Other
References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.
Name
Title
Relationship to You
Telephone
Number of Years Known
( )
( )
( )
Related Information
To what job-related organizations (professional, trade, etc.) do you belong?
Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.
Organization
Offices Held
List special accomplishments, publications, awards, etc.
Exclude information that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.
In your current or a previous job, have you ever written instructions or directions to be followed by employees or customers?

If yes, please explain:

Is there any other job-related information you want us to know about you?

Application Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and on-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. Understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, co-worker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement.

.CHECK THIS BOX TO CERTIFY THAT YOU HAVE READ AND ACCEPT THE ABOVE STATEMENT

 

IMMI
18881 U.S. 31 North
Westfield, IN 46074
MANDATORY QUESTIONS TO BE ANSWERED
Please complete the following questions. You will not be considered for employment without all answers being completed.
  1. Why did you leave your past employers?
  2. What were your past work responsibilities?
  3. Give complete names and phone numbers of past supervisors so we can contact them for references.
  4. What was the best job you ever had? Why did you like it so much?
  5. Think of the WORST supervisor or manager you’ve had. What made that person a POOR manager?
  6. What values or characteristics do you admire most in co-workers?
  7. What was the funniest thing that ever happened to you at work?
  8. Imagine you have been on your feet and working hard all day. A customer has a crisis that requires extra effort. What do you do?
  9. As part of our company policy, it is standard procedure to perform a criminal background check on someone we are considering for employment. Would you object to such a procedure?
Mandatory
IMMI
18881 U.S. 31 North
Westfield, IN 46074
Fair Credit Reporting Act Disclosure and Authorization
Fair Credit Reporting Act Disclosure and Authorization. This form must be completed for the application to be considered.

I understand that Indiana Mills & Manufacturing ("IMMI") and/or it's agents may conduct a background investigation and obtain a consumer report and/or an investigative consumer report for purpose of evaluating my employment or in determing whether to offer me a position. In the future, Indiana Mills & Manufacturing may obtain a consumer report and/or investigative consumer report for the purpose of determining your eligibility for rehire, continued employment, reassignment, or promotion.

I understand that this may include inquiries into my character, reputation, habits and mode of living; my employment and educational history and license status; my criminal and civil court records; my credit history; motor vehicle and driving records or experience; and other records. If hired, this authorization shall remain on file and shall serve as an on-going authorization for IMMI to procure consumer reports and/or investigative report is being requested, you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act.

My signature below authorizes IMMI to obtain a consumer report and/or an investigative consumer report.

 
Applicant's Name (Name as it appears on Social Security Card)
Other Names Used, Including Maiden Name:
Address: City: State: Zip:
Social Security Number: Date of Birth:
Driver's License Number: State:
Name as it appears on the Driver's License: A value is required.
Home Telephone Number: ( A value is required. ) A value is required.

CHECK THIS BOX TO CERTIFY THAT YOU HAVE READ AND ACCEPT THE ABOVE STATEMENT
 

To be completed by HR Department:
Witnessed by: Date:

 

Affirmative Action
IMMI
18881 U.S. 31 North
Westfield, IN 46074
Voluntary Information
Completion of information below is voluntary. 

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, military/veteran status, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. The information will be used and kept confidential in accordance with applicable laws and regulations.

 
Position(s) applied for:
Referral Souce:
Walk-In Government Employment Agency
Employee Relative
Advertisement | Source: Name of person who referred you (if applicable):
Last Name: First Name: Middle Name:
Address: City: State: Zip:
Male Female
EEO Self-Identification
Please check the box (only one) that best applies to you.
Minimum number of selections not met.Maximum number of selections exceeded. Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin: regardless of race.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific islands.
Asian (Not Hispanic or Latino) – a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the races above, excluding Hispanic or Latino.
Veteran Status Information
This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified special disabled veterans, veterans of the Vietnam era, recently separated veterans, and other protected veterans. If you are a veteran of the Vietnam era, recently separated veteran, or other protected veteran, we would like to include you under our affirmative action program. If you would like to be included under the affirmative action program, please tell us. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that: (i) supervisors and managers may be informed regarding restrictions on the work or duties of special disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) government officials engaged in enforcing laws administered by OFCCP, or enforcing the Americans with Disabilities Act, may be informed.
Please check all boxes that apply to you:
I am a veteran of the Vietnam ear. A person who: (A) served on active duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any part of such active duty occurred in: (i) the Republic of Vietnam between February 28, 1961 and May 7, 1975 or (ii) between August 5, 1964 and May 7, 1975, in all other cases; OR (B) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed during the times and places specified under (A).
I am a recently separated veteran. Any veteran during the one-year period beginning on the date of such veteran’s discharge or release from active duty.
I am an other protected veteran. A person who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized, under laws administered by the Department of Defense.
I would like to be included under the company’s affirmative action program (if applicable) pertaining to veterans of the Vietnam era, recently separated veterans, and other protected veterans. (Note that you may make this request at this time and/or any time in the future.)
None of the above apply to me.
Special Disabled Veterans (Applicant: Only complete this section if the Company has checked “Yes” below)
EMPLOYER: Please indicate whether you are inviting applicants to participate in your company’s affirmative action program benefiting special disabled veterans.

Yes. The Company invites its applicants to provide information (on a voluntary basis) regarding their status as a “special disabled veteran” for inclusion in the company’s affirmative action program.
Check this box ONLY if the company is actually undertaking affirmative action for special disabled veterans at the application state (pre-offer) or it otherwise authorized to collect this data to comply with federal, state, or local affirmative action obligations pertaining to special disabled veterans. Otherwise, it is advisable to wait until a conditional offer of employment has been extended before inquiring about disability status.

APPLICANT:
If the company has checked “Yes” to the question above, you are invited to provide additional information regarding your status as a “special disabled veteran”. This information will assist us in placing you in an appropriate position and in making accommodations for our disability. The law defines a “special disabled veteran” as”

a) a veteran who is entitled to compensation (or who, but for the receipt of military retired pay, would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability rated at 30 percent or more, or related at 10 or 20 percent in the case of a veteran who has been determined by the Department of Veterans to have a serious employment handicap, or
b) a person who was discharged or released from active duty because of a service-connected disability.

If you are a special disabled veteran, please indicate whether you would like to be included under the company’s affirmative action program for special disabled veterans. You may elect to be included at this time or any time in the future.

Yes. I would like to be included under the company’s affirmative action program for special disabled veterans. (If a job offer is extended, you may be asked to provide more information to assist with placement and accommodation issues.)

No. At this time, I would not like to be included in the company’s affirmative action program for special disabled veterans.

If you are a special disabled veteran, it would assist us if you tell us about any special methods, skills, and procedures which qualify you for positions that you might not otherwise be able to do because of your disability so that you will be considered for any positions of that kind.