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  1. Include State Issued (IA XXXXXXXXX)
  2. Have you ever been convicted of a violation of the law other than a minor traffic violation?*
  3. Are you eligible to work in the United States?*
  4. Position Information
  5. Type of employment desired*
    1. Education
    2. Graduated?
    3. G.E.D.
    4. Graduated:
    5. Graduated:
    6. Employment Information
    7. (From Most Recent)
    8. May we contact your previous supervisor for a reference?
    9. May we contact your previous supervisor for a reference?
    10. May we contact your previous supervisor for a reference?
    11. Other Information
    12. Military History
    13. Discharge:
    14. Qualifications and Skills
    15. (Office, Construction, Buses, Trucks, Etc.)
    16. Driver's License, Driving Record & Criminal History
    17. License EVER Suspended or Revoked?*
    18. EVER Convicted of a Crime?
    19. Dates and Reasons
    20. Have you reviewed the job description or posting for the position sought?
    21. If you don't reside within our required limits, are you willing to relocate?*
      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.
    22. References
    23. Please list three professional references.
    24. Disclaimer and Signature
    25. 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.
    26. 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.
    27. Leave This Blank:

    28. This field is not part of the form submission.