Form Center

Application For Employment

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.

   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.

     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.

     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.

     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")

Leave This Blank:


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