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Where you can be reached weekdays 8:30 a.m. - 4:30 p.m.
(Check all that apply)
(Proof of eligibility to work in the US will be required upon employment)
Falsification, misrepresentation 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
Please list all jobs held beginning with your present 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.
List professional, trade, business or civic activities and offices held. (You may exclude memberships which would reveal
race, color, creed, sex, national origin, age, veteran status or disability as provided by law.)
Summarize relevant job-related skills and qualifications you posses and/or any additional information you feel may be
helpful in considering your application.
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.
Give names, addresses and telephone numbers of two references who can speak to your ability to perform the functions of
the job for which you are applying.
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
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.
To aid in our recruitment efforts and remain within our Federal and State record keeping guidelines, we would appreciate
your compliance in completing the voluntary information below. This information is confidential, will be kept separate
from your application and will not affect your consideration for employment.
Applicants and employees are provided with an equal employment opportunity regardless of race, color, creed, sex,
national origin, age, veteran status or disability as provided by law.
This field is not part of the form submission.
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