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2. 
4. Valparaiso Police Department
   It is the policy of the City of Valparaiso to provide a harassment-free and equal employment opportunity work environment for all applicants and employees without regard to race, color, religion, gender, national origin, age, marital or veteran status, the presence of a medical condition or disability, or any other legally protected status. The City is committed to complying with all applicable federal, state and local regulations which provide protection from discrimination for various groups of applicants and employees. The City of Valparaiso maintains a Code of Ethics and specific policies regarding employee and applicant honesty, performance, conduct, and attendance. The City of Valparaiso reserves the right to investigate any suspected unethical or questionable activities and any violation of policies including, but not limited to falsification of records, the use, sale or possession of alcohol or drugs while working or working under the influence of drugs or alcohol, and the like. Violations of the City's policies will result in disciplinary actions which could include termination and prosecution. The employment relationship with the City of Valparaiso is at-will and employment can be terminated at any time, with or without cause of notice at the option of either the City or the employee. Questions about these policies may be addressed to Human Resources.
6. Last Name
7. First Name
9. Address1
11. City
12. State
13. Zip
15. Telephone Number
16. Are you between the age of 21 and 40 years old?

    1. Yes
    2. No
18. Position applied for
19. Department
20. Date
    Date
22. How did you learn about this position?
24. List days/hours available for employment interviews
26. Wage /Salary requirements (please specify)
28. Have you ever been employed by us?

    1. Yes
    2. No
29. If yes give date
    If yes give date
31. Are you related to anyone who works for the City of Valparaiso

    1. Yes
    2. No
32. If yes give the name and relationship to you
34. Are you currently employed?

    1. Yes
    2. No
35. Are you currently on "lay-off" status and subject to recall?

    1. Yes
    2. No
37. On what date would you be available for work?
    On what date would you be available for work?
39. Are you able to work: (check all that apply)

    1. Part-time (less than 35 hrs)
    2. Full-time (35 or more hrs)

    1. Additional Hours
    2. Overtime

    1. Weekends
    2. Shift Work

    1. Temporary Job
41. Are there any limitations on your work hours?

    1. Yes
    2. No
42. If yes, explain
44. Can you travel on day or overnight trips, if a job requires it?

    1. Yes
    2. No
46. Have you ever worked under a different name than currently used?

    1. Yes
    2. No
47. If yes, please provide name
49. Have you ever had any job related-training in the United States military?

    1. Yes
    2. No
50. If yes, please describe
52. Are you currently legally eligible (by reason of citizenship or legal alien status) for employment in the United States? (proof of eligibility to work in the U.S. will be required upon employment)

    1. Yes
    2. No
54. If you are under 18 years of age, do you have a work permit?

    1. Yes
    2. No
56. Have you ever been convicted of a felony?

    1. Yes
    2. No
57. If yes, list dates of conviction
    If yes, list dates of conviction Start Date

    If yes, list dates of conviction Start Time

    —

    If yes, list dates of conviction End Date

    If yes, list dates of conviction End Time
58. Type of offense(s)
60. Falsification, misrepresentations and/or omission of a felony conviction is grounds for refusal to hire, or if hired, for dismissal. A conviction does not automatically disqualify an applicant from employment. The date, nature, and seriousness of the offense will be considered.
64. EDUCATION (Enter school name, address, and highest level completed)
66. Elementary
68. High School
70. Undergraduate
72. Graduate
74. Diploma/Degree
76. Course of Study
78. Specialized training apprenticeship, skills,etc.
80. Honors you have received
82. JOB RELATED ACTIVITIES
84. List professional, trade, business or civic activities and offices help. (You may exclude memberships which would reveal, race, color, creed, sex, national origin, age, veteran status, or disability as provided by law)
88. SPECIALIZED SKILLS AND QUALIFICATIONS
90. Summarize relevant job-related skills and qualifications you possess and/or any additional information you feel may be helpful in considering your application.
92. List current licensures, certifications, including drivers license, CDL license number, etc. If applicable, include date received and expiration date. If a certification or license was not issued in Indiana, please indicate the state where issued.
96. REFERENCES
    (list name, relationship, and address)
100. EMPLOYMENT EXPERIENCE
     Please list all jobs held beginning with your present employer or most recent job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disability or other protected status.
102. Employer
103. Type of Business
105. Address1
107. City
108. State
109. Zip
111. Employer Telephone No.
112. Position Title
114. Employed from/to
     Employed from/to Start Date

     —

     Employed from/to End Date
115. Salary Beginning
116. Salary Ending
118. Employment

     1. Full-time
     2. Part-time
     3. Temporary
119. Supervisor
121. Description of Work
123. Reason for leaving
125. If the employer were asked, is this the same reason they would give?

     1. Yes
     2. No
127. If no, please explain
129. Were you involuntarily terminated from this position?

     1. Yes
     2. No
131. Do you authorize us to contact this employer at this time?

     1. Yes
     2. No
133. Have you ever been on reprimanded, suspended, placed on probation, or discharged for attendance, tardiness, or work performance?

     1. Yes
     2. No
135. If yes, please explain
139. Employer
140. Type of Business
142. Address1
144. City
145. State
146. Zip
148. Employer Telephone No.
149. Position Title
151. Employed from/to
     Employed from/to Start Date

     —

     Employed from/to End Date
152. Salary Beginning/Ending
154. Employed

     1. Full-time
     2. Part-time
     3. Temporary
155. Supervisor
157. Description of Work
159. Reason for leaving
161. If the employer were asked, is this the same reason they would give?

     1. Yes
     2. No
163. If no, please explain
165. Do you authorize us to contact this employer at this time?

     1. Yes
     2. No
167. Have you ever been on reprimanded, suspended, placed on probation, or discharged for attendance, tardiness, or work performance?

     1. Yes
     2. No
169. If yes, please explain
173. Employer
174. Type of Business
176. Address1
178. City
179. State
180. Zip
182. Employer Telephone No.
183. Position Title
185. Employed from/to
     Employed from/to Start Date

     —

     Employed from/to End Date
186. Salary Beginning/Ending
188. Employed

     1. Full-time
     2. Part-time
     3. Temporary
189. Supervisor
191. Description of Work
193. Reason for leaving
195. If the employer were asked, is this the same reason they would give?

     1. Yes
     2. No
197. If no, please explain
199. Do you authorize us to contact this employer at this time?

     1. Yes
     2. No
201. Have you ever been on reprimanded, suspended, placed on probation, or discharged for attendance, tardiness, or work performance?

     1. Yes
     2. No
203. If yes, please explain
207. Employer
208. Type of Business
210. Address1
212. City
213. State
214. Zip
216. Employer Telephone No.
217. Position Title
219. Employed from/to
     Employed from/to Start Date

     —

     Employed from/to End Date
220. Salary Beginning/Ending
222. Employed

     1. Full-time
     2. Part-time
     3. Temporary
223. Supervisor
225. Description of Work
227. Reason for leaving
229. If the employer were asked, is this the same reason they would give?

     1. Yes
     2. No
231. If no, please explain
233. Do you authorize us to contact this employer at this time?

     1. Yes
     2. No
235. Have you ever been on reprimanded, suspended, placed on probation, or discharged for attendance, tardiness, or work performance?

     1. Yes
     2. No
237. If yes, please explain
241. Employer
242. Type of Business
244. Address1
246. City
247. State
248. Zip
250. Employer Telephone No.
251. Position Title
253. Employed from/to
     Employed from/to Start Date

     —

     Employed from/to End Date
254. Salary Beginning/Ending
256. Employed

     1. Full-time
     2. Part-time
     3. Temporary
257. Supervisor
259. Description of Work
261. Reason for leaving
263. If the employer were asked, is this the same reason they would give?

     1. Yes
     2. No
265. If no, please explain
267. Do you authorize us to contact this employer at this time?

     1. Yes
     2. No
269. Have you ever been on reprimanded, suspended, placed on probation, or discharged for attendance, tardiness, or work performance?

     1. Yes
     2. No
271. If yes, please explain
275. Please use the links below to provide any additional information.
277. Cover Letter
278. Resume
279. Supporting Document
283. ACKNOWLEDGMENT OF TERMS OF APPLICATION
     I certify that the information contained in this application, and accompanying resume, if any, is true and complete to the best of my knowledge and understand that falsification, misrepresentation and/or omission of information is grounds for refusal to hire, or if hired, dismissal. In making this application for employment, I authorize the City of Valparaiso to check employment and personal references, and to seek the release of investigatory information, including a “limited criminal history,” possessed by any private or public employer or any local, state, or federal agencies to provide the City of Valparaiso any information they may release concerning the matters described herein or pertaining to questions herein, and I will cooperate to the extent necessary to obtain the release of this information. I understand that this investigation report of my employment history and background may be made whereby information is obtained through personal interviews and/or reference forms with third parties, law enforcement agencies prior employers, co-workers, or others. This inquiry may include information as to my character, general reputation, personal characteristics, work habits, and mode of living, whichever may be applicable. I expressly waive in connection with any request for, or provisions of such information, any claims or cause of action including without limitation, defamation, infliction or emotional distress, invasion of privacy, or interference with contractual relations that I might claim or otherwise have against the City of Valparaiso, its officials, employees, trustees or agents, or against any provider of information related to this application or the application process. This authorization does not include release or other prohibited use of disability and medical related information prohibited in pre-employment inquires by the Americans with Disabilities Act (ADA). In the event of my employment, I agree to conform to policies of the City of Valparaiso and acknowledge that these policies may be changed, interpreted, withdrawn, or added to by the City at any time, at the City's sole option and without prior notice to me. I understand that this application will be given every consideration, but its receipt does not imply that I will be employed. I understand that this employment application and any other City of Valparaiso documents are not contracts of employment, and that my employment will be employment at-will and may be terminated at any time, with or without cause or notice, at the option of either the City or myself. If hired, I understand that no modification or alteration of my employment at-will status shall be valid or binding, unless it is expressly set forth in a written document by the Board of Works. I understand that the City of Valparaiso will require me to undergo a drug test by medical staff and/or agent selected by the City as a condition of my employment. I consent to the release of my drug test result to the City. I further understand that I must successfully pass the drug test to be considered for employment with the City of Valparaiso. I understand that medical examinations which are job-related and consistent with the City's business necessity may be required of me once I am employed. I further release the City of Valparaiso, including all of its officers, agents, representatives and employees from any and all claims, suits, causes of action, liabilities and damages associated with or arising from my submission to a drug test and/or medical examination. I also understand the City may maintain a restricted smoking environment. I certify that the information in this application is correct and complete. I understand that if offered employment, my employment is contingent upon successfully completing all aspects of the post-offer pre-employment and reference checking processes.
285. ELECTRONIC SIGNATURE AGREEMENT
     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
287. Electronic Signature

     1. I Agree
289. (field for signature with placeholder text: "First M. Last")
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291. 1. Receive an email copy of this form.
292. Email address

     This field is not part of the form submission.

293. Submit

* indicates a required field