Road to Success Application Your road to Success Starts Here This online application is for participation in the Road to Success program, a part-time opportunity for Commercial Tire Service Technicians with 100% tuition reimbursement at Indiana University Southeast. Where did you hear about the Road to Success program?*At My High SchoolAt Indiana University SoutheastOnline / WebsiteA Friend or Family MemberOtherFull Name* Email Address* Enter Email Confirm Email We will only use your email address to contact you regarding job opportunities. We do not use any email addresses for marketing, or provide email addresses to any outside sources.Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you legally authorized to work in the United States?* Yes No Social Security Number* Phone NumberHave you ever been convicted of a crime?* No Yes A "Yes" answer will not automatically disqualify you from employment. We will consider the date, nature, and circumstances of the offense, for job related purposes only, and only to the extent permitted by law.Conviction DetailsPlease provide conviction dates and any relevant details.Have you ever used names or SSNs other than that listed above?* No Yes Please list any other names or SSNs that you have previously used.EducationHigh School Attended Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you graduate from high school? Yes No Acquired GED or Equivalent Have you applied to Indiana University Southeast? Applied But Not Yet Accepted Applied and Accepted Not Yet Applied Already Atteding What type of degree are you interested in pursuing? Military ExperienceHave you ever served in the United States Military?* Currently Serving Previously Served No Branch of Service Occupational Specialty Highest Rank Obtained Date of Discharge MM slash DD slash YYYY Type of Discharge Describe any applicable military education and training.Current EmploymentMost Recent Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position or Title Duties and ResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Supervisor Name First Last Base Pay or Salary Reason for Leaving May we contact this employer? Yes No Have you read the Position Description for Commercial Tire Service Technician?* Yes No Position Description for Commercial Tire Service TechnicianDo you believe that you are able to perform the all of the job duties as described in the Position Description?* Yes No Have you read and understood the Road to Success Program Details?* Yes No Road to Success Program DetailsAre you willing to submit to pre-employment and subsequent random drug screenings?* Yes No Are you willing to submit to pre-employment and subsequent job-related medical reviews?* Yes No Driving EligibilityDo you have a valid driver's license, in good standing, issued by the state in which you reside?* Yes No Issued by another state Type of License (Operator, CDL, etc.) Issuing State Have you been convicted of any moving violations in the last seven years?* No Yes Dates and Details of Moving ViolationsHave you EVER been convicted of driving under the influence of drugs or alcohol, or of reckless driving?* No Yes Dates and Details of DUI, DWI, or Reckless Driving ConvictionsResumé UploadIf you have a prepared resumé that you would like to provide, you can upload it here.Upload Your Resumé (Optional)Accepted file types: pdf, doc, docx, txt, Max. file size: 2 MB.We accept Microsoft Word Documents (DOC, DOCX), Adobe PDF, or Plain Text Documents (TXT).Authorizations and AcknowledgementsI hereby certify that the information that I provided is true and complete to the best of my knowledge. i understand that, if employed, any false statements contained herein shall be grounds for termination of employment.* Agree Disagree Digital Signature* Typing your name in the field above constitutes your digital signature, and your agreement to all of the terms listed above.PhoneThis field is for validation purposes and should be left unchanged. 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