2. First Name*
3. Last Name*
5. Street Address*
   Must be within the city limits of the City of Michigan City and cannot be a PO Box.
6. Suite or Apartment Number
8. Mailing Address
   (if different from street address)
10. City*
11. State*
12. Zip Code*
14. Primary Phone*
15. Secondary Phone
17. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
18. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
20. Email Address*
21. Fax Number
23. WorkOne Workkeys Testing Results*
    To be added to the Hiring Registry List, you MUST complete the WorkOne Workkeys testing and include copy of your results with your registry application.
25. I am:

    1. a female seeking employment
    2. a minority seeking employment
    3. a veteran seeking employment
26. Specify Race or Ethnicity (optional)
28. A member of a union*

    1. Yes
    2. No
29. If yes, which union?
31. Your trade*

    (Check all that apply)

    1. Boilermaker
    2. Carpenter
    3. Cement Worker
    4. Electrician

    1. General Laborer
    2. Glaziers
    3. Insulation Worker
    4. Iron Worker

    1. Plumber
    2. Roofer
    3. Other (please explain)
33. Please explain Other
35. Please list any other special qualifications and/or certifications
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field