Personal Information
Home Phone
Work Phone
Drivers License Info
*Do you have a valid driver's license?
Yes
No
Please make a selection.
Drivers License Number
Drivers License State
Employment Questionnaire
*Are you willing to take a drug test if required as part of your application and/or employment?
Yes
No
Please make a selection.
*If a hiring decision is made, will you answer a medical questionnaire?
Yes
No
Please make a selection.
*Are you willing to take a math exam as part of your application?
Yes
No
Please make a selection.
*Are you legally eligible for employment in the U.S.?
Yes
No
Please make a selection.
*Will you work overtime or shift work?
Yes
No
Please make a selection.
*Are you color blind?
Yes
No
Please make a selection.
*Do you currently hold an electrician’s license?
Yes
No
Please make a selection.
*Have you ever been enrolled in a Federal (B.A.T.) or state approved (S.A.C.) apprenticeship program?
Yes
No
Please make a selection.
Education
*Did You Graduate Highschool?
Yes
No
Please make a selection.
*GED Graduate?
Yes
No
Please make a selection.
College / Vocational Training
Miltary / Vocational Training
Vocational / Military Electrical Courses
Other Vocational Training
Employment History
Current Employer
Current Employer City
Current Employer Phone Number
Current Employer Start Date
Number Of Years At Current Employer
Current Salary
Current Job Title
Description Of Duties
Reason For Leaving
Previous Employer
Previous Employer City
Previous Employer Phone Number
Previous Employer Start Date
Number Of Years At Previous Employer
Previous Salary
Previous Job Title
Description Of Duties
Reason For Leaving
Privacy Act Statement
The Information request herein is a voluntary disclosure and is used for Apprentice Program
Statistical Purposes and will only be disclosed in accordance with the provisions of the Privacy
Act (Privacy Act 0f 1974- P.L - 93-579)
Race / Ethnic Group (Optional)
White (not Hispanic)
Black
Hispanic
Asian or Pacific Islander
American Indian or Alaskan Native
Other (not classified)
Military Status (Optional)
Non-Military
Veteran
Highest Education Level Completed (Optional)
GED
High School Graduate
College
Notice To Applicants
This organization does not require a pre-acceptance medical examination, but the contractor members of this
organization do reserve the right to require drug testing and/or a medical examination after an offer of
employment is made to an applicant. Offers of employment are conditioned upon the passing of a drug test for
the purpose of detecting the illegal use of drugs. Also, if an employment offer is made, you may be asked to
answer certain medical questions. An applicant will not be excluded from employment unless they have medical
conditions that prohibit their ability to perform the essential job functions of electrical apprentice, with
or without reasonable accommodations.
Representations & Waivers
Read the following conditions. If you have any questions regarding the conditions, you should ask for a
full explanation or clarification from the IEC office (219-900-0091). Signify your understanding and specific
acceptance of each condition by your signature in the space provided at the end of this form.
I hereby authorize the Independent Electrical Contractors Association to investigate any and all statements
contained in this application. I hereby consent to the IEC Association conducting any checks concerning by
background which are deemed necessary, advisable or helpful by the IEC Association (except contracting my
current employer, unless permission is granted above). I understand that failure to produce a valid driver’s
license and a clean driving record will not prohibit my acceptance into the program but may limit the ability
of the IEC to place me with a member. I may be required to submit to a drug test. I hereby consent to a drug
test and waive any and all objections I might otherwise have to such a drug test. I understand that all statements
made this application are true and complete to the best of my knowledge and without mental reservations. I
understand that falsification of this application may result in my not being considered for acceptance or, in the
event that I am accepted by the Independent Electrical Contractors Association, in my dismissal from the program.
