Skip to main content
Stone Belt Divisions :  Milestones Clinical & Health Resources 

Apply Banner


For your convenience, you may begin the application process now by completing the mini application below. All fields are required unless otherwise indicated.

You may also complete an application at any one of our Stone Belt locations. Or, you may download an application in PDF format and submit it directly to Stone Belt at 2815 East 10th Street, Bloomington, IN 47408 Attn: Hire Me, via email or in person. Please submit email files in .doc format instead of Office 2007 .docx.

We will personally contact qualified applicants to arrange an interview. If you are selected for an interview, you will be asked to complete the full employment application.

Current employees should complete an internal application.



Complete an Employment Application

Required fields are marked with an asterisk (*).

Step 1: Position Information

Step 1: Position Information

Date of application*

Position applying for*

Where did you learn about this position?

Newspaper - Specify:

Internet - Site:

Unemployment Office - Specify:

Job Fair - Specify:

Reputation in Community - Specify:

Other - Specify:

Step 2: Personal Data

Full Name (Last, First, Middle Initial)*


Street Address*


City*


State*


Zip*


Phone Number*


Alternative Number*


Email


Are you 18 years or older?
Yes No

Step 3: Employment Questions

Step 3: Employment Questions

1. Are you related to any Stone Belt employee or Board member?
Yes No
If yes, list name(s):


2. Have you ever been employed at Stone Belt before?
Yes No
If yes, when?


3. Have you worked under any previous name(s)?Yes No 
If yes, list name(s):


4. Verification of you legal right to work in the United States will be required after employment. (Some examples include: driver's license, social security card, birth certificate, US military card, INS employment authorization). Will you be able to supply such verification?
Yes No

5. Are you on a layoff and subject to recall at another employer?
Yes No

6. If hired, will you be able to perform the essential functions of the job you have applied for?
Yes No

7. During the last ten years, have you ever been convicted of a crime that has not been expunged by a court?
Yes No
If yes, please explain in detail, including the date of the incident:

(Note: A conviction will not automatically disqualify you for employment. Factors such as date of conviction, seriousness and nature of the crime, and rehabilitation will be considered).

8. Do you have a valid driver's license?
Yes No

9. Have you received any moving violations (speeding or traffic tickets) or a DUI/DWI/OWI in the last five years?
Yes No
If yes, please explain:


Step 4: Educational Information

Step 4: Educational Information


School
Name/
Location
Course of Study
Level Completed
Did you graduate
Degree
Name
High School



College





Graduate/Professional





Business/Vocational






List any job-related special skills acquired, seminars attended, job training received, machines you can operate, computer programs, etc.:


Honors received, professional memberships, offices:


Step 5: Employment History

Step 5: Employment History


List employment starting with your most recent positions. Please give an accurate and complete record of all full/part-time employment in the space provided and account for all periods of unemployment. DO NOT write "see resume" or "see previous application." This section must be filled out completely, or this application will not be processed.


   
Company Name:


Employer/Address


Phone


Email


Supervisor's Name


Dates Employed
From (mm/yyyy) To (mm/yyyy)

Number of Hours Per Week:


Hourly Rate/Salary
Starting Final

Job Title/Duties


Reason for Leaving

Voluntary Resignation Involuntary Resignation 
 
Company Name:


Employer/Address


Phone


Email


Supervisor's Name


Dates Employed
From (mm/yyyy) To (mm/yyyy)

Number of Hours Per Week:


Hourly Rate/Salary
Starting Final

Job Title/Duties


Reason for Leaving

Voluntary Resignation Involuntary Resignation 
 
Company Name:


Employer/Address


Phone


Email


Supervisor's Name


Dates Employed
From (mm/yyyy) To (mm/yyyy)

Number of Hours Per Week:


Hourly Rate/Salary
Starting Final

Job Title/Duties


Reason for Leaving

Voluntary Resignation Involuntary Resignation 

Personal References - DO NOT include supervisor already listed above or any relatives.

Name
Phone Number
Email
Relationship
Years Acquainted





















Step 6: Volunteer Experience

Step 6: Volunteer Experience


List volunteer positions held starting with your most recent position. Please give an accurate and complete record of all volunteer experience obtained in the space provided. DO NOT write "see resume" or "see previous application." This section must be filled out completely, or this application will not be processed.


   
EXPERIENCE #1
Organization/City



Phone


Contact Person


Dates
From (mm/yyyy) To (mm/yyyy)

Duties:


EXPERIENCE #2
Organization/City



Phone


Contact Person


Dates
From (mm/yyyy) To (mm/yyyy)

Duties:


EXPERIENCE #3

Organization/City


Phone


Contact Person


Dates
From (mm/yyyy) To (mm/yyyy)

Duties:


Step 7: Upload a Résumé(Optional)

Upload a Résumé

Select résumé/CV file from your PC:

Supported file types(.pdf, .txt, .rtf, .doc, .docx, .html)

Step 8: Certification

Step 8: Certification


CERTIFICATION

I hereby authorize the release of any data relevant to my employment with Stone Belt for the purpose of an employment investigation. I authorize a thorough investigation of my past employment, activities, volunteer experience, criminal history, and, when required for a position, my driving record. I agree to cooperate in such investigation, and release from all liability or responsibility all persons and corporations requesting or supplying such information. I understand that Indiana law provides immunity to my previous employers when they disclose information about my employment history, unless the information disclosed was known to be false at the time the disclosure was made.

I agree to submit to any lawful drug, alcohol, or other testing that may be required as a condition of employment or continued employment and understand that refusal to promptly submit and cooperate with such testing prior to or during the course of my employment will result in disqualification from consideration for employment or, if hired, termination.

I fully understand that if employed, any misrepresentation or omissions on this application or on any other Stone Belt record will result in dismissal, regardless of the date of discovery. I acknowledge that employment is also subject to a satisfactory review of my references.

This organization takes abuse very seriously. Abuse in any form will not be tolerated.

Neither this application nor any statement made to me during the hiring process or thereafter shall be considered a contract of employment of any kind. Where such a contract is intended, I understand that it will be separately entered into and signed by the Chief Executive Officer of Stone Belt. Absent such a contract, I understand that, if hired, my employment will be terminable-at-will, with or without cause or notice, that I am not being employed for any specific or definite period of time, and that this application is not and is not intended to be a contract, offer, statement, or confirmation of or for continued employment. I understand that any employee handbook or manual does not represent an employment contract if I am hired, and Stone Belt may alter, modify, amend, or terminate any of its policies and benefits, both as to active and retired employees.

DECLARATION

I declare that I have never committed an act of abuse or fraud in relationship to a dependent person or any crime not disclosed on this application. I declare that I have never knowingly violated applicable rules or laws in any previous employment in residential, health care, or related employment. I understand that a criminal history check will be performed, a drug test administered, and that any ineligibility for coverage by Stone Belt’s vehicle insurance policy may result in ineligibility for employment or immediate termination should it occur in the future.


Applicant Electronic Signature


Date (mm/dd/yyyy)




Please enter AMIHUMAN above.