Public Application - Urschel Laboratories

APPLICATION FOR EMPLOYMENT

Equal Employment Opportunity/Non-Discrimination Policy

It is the policy of Urschel Laboratories, Inc. not to discriminate on the basis of ethnicity, race, color, religion, gender, national origin, age, disability, veteran status or any other protected class, in its hiring decisions and employment policies, as required by the Indiana Civil Rights Act (I.C. 22-9, 1), Title VI and VII (Civil Rights Act of 1964), the Equal Pay Act of 1973, and any other applicable law.

Open Positions:*

Date*

First Name:*

Middle Initial:

Last Name:*

Street Address:*

P.O. Box:

City:*

State:*

Zip Code:*

Country:*

Email Address:

Contact Phone:*

Upload Resume(s)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

Education

High School Graduate:*

Yes

No

General Education (GED) Test Passed?*

Yes

No

High School Name:*

City:*

State:*

College

College or technical school attended:

Location:

Major/Field:

Graduated?

Yes

No

Degree:

GPA:

Currently enrolled?

Yes

No

If degree is incomplete, list number of credit hours completed:

Additional Courses or Certifications

College or technical school attended:	Location:	Major/Field:	Graduated?	Degree:	GPA:	Currently enrolled:	If degree is incomplete, list number of credit hours completed:	Actions

There are no Entries.

Additional commercial or technical courses taken:

Military

Military Experience:*

Yes

No

Branch:

Location:

Date of Service:

Rank of Military:

Skills:

Duties:

Work Experience

Please list ALL of your work experience, starting with your present or more recent employment. Include information on military service. Complete in full even if your resume is enclosed.

Present/Most Recent Employer:*

Job Title*

City:*

State:*

Phone:*

Start Date*

Still employed?*

Yes

No

End Date*

Average hours/week worked:*

Specific reason for leaving:*

Please include a short summary of your main job duties:*

Beginning Salary:*

Ending Salary:*

Supervisor's Name:*

Previous Employers

Previous Employer:	Job Title:	City:	State:	Phone:	Average hours per week worked:	Specific reason for leaving:	Please include a short summary of your main job duties:	Beginning Salary:	Ending Salary:	Supervisor’s Name:	Start Date	End Date	Actions

There are no Entries.

How did you hear about us?

Where did you hear about the job posting?*

Please specify where you heard about us:*

Please specify who referred you:*

References

Please indicate the names of two work or professional references that are familiar with your skills or abilities.

Reference Name:*

Reference Phone:*

Reference Email:*

Reference Affiliation:*

Second Reference:

Reference Name:*

Reference Phone:*

Reference Email:*

Reference Affiliation:*

Please indicate any experience, special aptitudes, or skills that you feel you have that pertain to the position for which you are applying:

Summarize any additional information necessary to describe your full qualifications, professional objectives, or goals:

Questions

Are you presently being investigated, or under a procedure to consider your discharge for misconduct by your present employer?*

Yes

No

Have you ever been suspended, discharged, or asked to resign from a prior position?*

Yes

No

Have you ever resigned from a prior position without being asked, under circumstances involving your employer's investigation for sexual misconduct with another person, mishandling of funds, or criminal conduct?*

Yes

No

Any "yes" answers must be explained in the area below including date of incident, charge or offense in question, court action taken, and the address of any court involved.*

Have you ever interviewed for a position with Urschel before?*

Yes

No

Please list position:*

Name: {First Name:139} {Middle Name(s):140} {Last Name:141}

Date: 03/21/2025

Positions Applied For: {Positions Applied For::1}

Referral Source: {Where did you hear about the job posting?:98} {Please specify where you heard about us::99} {Please specify who referred you::134}

Voluntary Self-Identification of Disability

Name: {First Name:139} {Middle Name(s):140} {Last Name:141}

Date: 03/21/2025

Form CC-305
OMB Control Number 1250-0005
Expires 04/30/2026

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do I know if I have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

Alcohol or other substance use disorder (not currently using drugs illegally)
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
Blind or low vision
Cancer (past or present)
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or serious difficulty hearing
Diabetes
Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
Epilepsy or other seizure disorder
Gastrointestinal disorders, for example, Crohn’s Disease, or irritable bowel syndrome
Intellectual or developmental disability
Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
Missing limbs or partially missing limbs
Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
Partial or complete paralysis (any cause)
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
Short stature (dwarfism)
Traumatic brain injury

Please select one of the Voluntary Self-Identification of Disability boxes below:*

Yes, I have a disability, or have had one in the past

No, I do not have a disability and have not had one in the past

I do not want to answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Self-ID Form for Veterans

This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

A “disabled veteran” is one of the following:
- a veteran of the U.S. military, ground, naval, or air service 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 Secretary of Veterans Affairs; or
- a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under the Uniformed Services Employment and Reemployment Rights Act (USERRA). In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

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 VEVRAA.

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 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 the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Please select one of the Self-ID for Veterans boxes below:*

I AM A VETERAN UNDER ONE OF THE CLASSIFICATIONS LISTED ABOVE

I AM NOT A VETERAN UNDER ONE OF THE CLASSIFICATIONS LISTED ABOVE

[OPTIONAL] I AM A MILITARY SPOUSE

[OPTIONAL] I AM A RECENTLY SEPARATED VETERAN

[OPTIONAL] I AM A MEMBER OF A STATE OR NATIONAL GUARD

[OPTIONAL] ADD IN ADDITIONAL VETERANS GROUPS/MEMBERSHIP

[OPTIONAL] I AM ANOTHER TYPE OF VETERAN NOT LISTED ABOVE

I DO NOT WISH TO DISCLOSE THIS INFORMATION

Discharge/Release Date*

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 VEVRAA.

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 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 the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Application Review

Please review your answers, sign and submit the form below.

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Agree & Sign

Applicant Statement

I certify that all statements I have made on this application and on my resume or any other supplementary materials are true and correct. I acknowledge that any false statement or misrepresentation on this application, my resume, or supplementary materials will be cause for refusal to hire, or for immediate termination of employment at any time during the period of my employment.

I understand and agree that, if I am offered a position, it will be offered on condition that my employment will be at will and for no definite period, and that my employment may be terminated, at any time, with or without cause and with or without prior notice.

Signature/Printed Name of Applicant:*

Date: 03/21/2025

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Name

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Application for Employment

APPLICATION FOR EMPLOYMENT

Equal Employment Opportunity/Non-Discrimination Policy

Education

College

Military

Work Experience

How did you hear about us?

References

Questions

Voluntary Self-Identification of Disability

Self-ID Form for Veterans

Application Review

Agree & Sign

Applicant Statement