Form Center

2. Last Name*
3. First Name*
4. Middle Name*
6. Address1*
8. City*
9. State*
10. Zip*
12. Home Phone Number*
13. Cell Phone Number
15. Drivers License Number*
    Include State Issued (IA XXXXXXXXX)
16. Email Address*
18. Have you ever been convicted of a violation of the law other than a minor traffic violation?*

    1. Yes

    1. No
20. Are you eligible to work in the United States?*

    1. Yes

    1. No
22. Upload Your Resume
26. Position Information
28. Which position are you applying for?*
30. Type of employment desired*

    1. Full Time

    1. Part Time

    1. Seasonal/Temporary
32. How did you hear about the position?
    -- Select One --NewspaperFriendWebsiteSocial MediaRadioOther
36. Education
38. High School
39. Address
41. Graduated?

    1. Yes
    2. No
42. G.E.D.

    1. Yes
    2. No
43. Vocational Program
45. College
46. Address
48. Graduated:

    1. Yes
    2. No
49. Degree
51. Other
52. Address
54. Graduated:

    1. Yes
    2. No
55. Degree
59. Employment Information
61. (From Most Recent)
63. Company
64. Position
66. Supervisor
67. Phone Number
69. May we contact your previous supervisor for a reference?

    1. Yes

    1. No
71. Address
73. Responsibilities
75. Employed From - To (Date)
76. Salary
78. Reason for Leaving
82. Company
83. Position
85. Supervisor
86. Phone Number
88. May we contact your previous supervisor for a reference?

    1. Yes

    1. No
90. Address
92. Responsibilities
94. Employed From - To (Date)
95. Salary
97. Reason for Leaving
101. Company
102. Position
104. Supervisor
105. Phone Number
107. May we contact your previous supervisor for a reference?

     1. Yes

     1. No
109. Address
111. Responsibilities
113. Employed From - To (Date)
114. Salary
116. Reason for Leaving
120. Other Information
122. Military History
124. Military Branch
125. Rank
126. Duties
128. Discharge:

     1. Honorable
     2. Other (Please explain)
129. Explanation
131. Qualifications and Skills
133. Describe Any Equipment Extensively Operated By You
     (Office, Construction, Buses, Trucks, Etc.)
135. List Any Specialized Training, Certificates or Achievements
137. Driver's License, Driving Record & Criminal History
138. Current License*
     -- Select One --DriverChauffeurCommercial Driver LicenseNone
140. License EVER Suspended or Revoked?*

     1. Yes
     2. No
141. If yes, List ALL Suspensions & Revocations
143. EVER Convicted of a Crime?

     1. Yes
     2. No
144. If yes, List ALL convictions, including ALL misdemeanors, OWIs, etc
     Dates and Reasons
146. Have you reviewed the job description or posting for the position sought?

     1. Yes
     2. No
148. If you don't reside within our required limits, are you willing to relocate?*

     1. Yes
     2. No

     Firefighters and command officers of the fire department must reside within ten (10) air miles of the City limits. All other employees must reside with in Des Moines County, or within fifteen (15) air miles if outside Des Moines County.
152. References
154. Please list three professional references.
156. Full Name*
157. Relationship*
159. Company*
160. Phone Number*
164. Full Name*
165. Relationship*
167. Company*
168. Phone Number*
172. Full Name*
173. Relationship*
175. Company*
176. Phone Number*
180. Disclaimer and Signature
182. The City of Burlington Does Not Discriminate On The Basis of Race, Color, National Origin, Sex, Sexual Orientation, Gender Identity, Religion, Age, Or Disability in Employment or the Provision of Services.
184. I hereby certify that the answers given and statements made by me on this Employment Application are true & correct & that there there are no material omissions. I authorize my present and former employers to give City officials any information regarding me or my performance and release such employers, including their representatives & their companies, from all liability from damage for providing requested information. I understand that should investigation disclose misrepresentation or falsification, I will be dismissed immediately, my application will be rejected and I will be disqualified from making future application with the City.
     
     I understand that any employment offered by the City is "employment at will" & I may be terminated for any reason not violative of law (or a collective bargaining agreement where applicable). I understand my driving and any criminal records may be checked and I agree to submit to a pre-employment physical examination at City expense following a conditional offer of employment. I also understand that the City of Burlington has a strict policy against illegal drug involvement by employees that can result in immediate disqualification or dismissal from employment for any such illicit activities occurring on or off the job. I also understand the City strictly enforces the Iowa Smokefree Air Act and employees violating said Act are subject to discipline, up to & including discharge.
     
     Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.
186. Applicant Signature*
Leave This Blank:


188. 1. Receive an email copy of this form.
189. Email address

     This field is not part of the form submission.

190. Submit Submit and Print

* indicates a required field