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Personal Information

First Name*
Last Name*
Email*
Phone Number*
Address*
City*
State*
Zip Code*
Applicants for Patrol Officers or Full-time firefighters must be at least 21 years of age and under 36 years of age.
Are You 18 Years of Age or Older?*
1. Yes
2. No
Are You Legally Eligible to Work in the United States?*
1. Yes
2. No
Have You Previously been Employed by the City?*
1. Yes
2. No
Provide Dates of Prior City Employment
Do You Currently Have or Ever Had a Relative Employed by the City?*
1. Yes
2. No
List Relative Names and Relationships
Have You Ever Been Arrested or Convicted of a Crime That Has Not Been Expunged by a Court?*
1. Yes
2. No
Please Explain
Position(s) Desired*
Date Available to Begin Work*
Date Available to Begin Work
Desired Hourly Rate or Base Salary
Type of Work Desired*
1. Full-time
2. Part-time
Schedule Availability*
1. Weekday / Daytime Hours
2. Weekday / Evening Hours
3. Saturdays
4. Sundays
Are You Currently Employed?*
1. Yes
2. No
If Yes, May We Contact Your Present Employer?
1. Yes
2. No
Do You Have Any Special Skills, Volunteer Experience, and/or Training that would Enhance Your Ability to Perform the Applied for Position?*
1. Yes
2. No
Please List and Explain
Do You Hold any Licenses or Professional Certifications?*
1. Yes
2. No
Please Specify
Do You Participate in Any Professional Associations that would Enhance Your Ability to Perform the Applied for Position?*
1. Yes
2. No
Please List and Explain
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Personal References

Please List Three Persons not Related to You and Preferably Who You Have Worked with/for and Have Known for at Least Three Years.
Reference 1 :
Name*
Company Name
Years Known*
Phone Number*
Email
Address*
Reference 2 :
Name*
Company Name
Years Known*
Phone Number*
Email
Address*
Reference 3 :
Name*
Company Name
Years Known*
Phone Number*
Email
Address*
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Employment History

Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.
Employment Date Started*
Employment Date Started
Employment Date Ended
Employment Date Ended
Employer's Name*
Employer's Address*
Position/Title Held*
Rate of Pay
Reason for Leaving
Supervisor's Name/Title*
Phone Number
Briefly Describe Duties*
Employment Start Date
Employment Start Date
Employment End Date
Employment End Date
Employer's Name
Employer's Address
Position/Title Held
Rate of Pay
Reason for Leaving
Supervisor's Name/Title
Phone Number
Briefly Describe Duties
Employment Start Date
Employment Start Date
Employment End Date
Employment End Date
Employer's Name
Employer's Address
Position/Title Held
Rate of Pay
Reason for Leaving
Supervisor's Name/Title
Phone Number
Briefly Describe Duties
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Education

Review and Complete

Please Read Carefully before Signing:
The City of Bluffton is an equal opportunity employer. The City of Bluffton does not discriminate in employment on account of race, color, religion, sex (pregnancy, gender identity, and sexual orientation), national origin, age (40 and over), disability, genetic information as referenced in the Genetic Information Nondiscrimination Act (GINA), military service veteran status or any other protected class as defined by federal, state, and local laws. The City of Bluffton will comply with its obligation to provide reasonable accommodation to qualified individuals with disabilities.
I understand that neither the completion of this application nor any other part of my consideration for employment establishes an obligation for the City of Bluffton to hire me. If I am hired, I understand that either the City of Bluffton or I may terminate employment at any time for any reason, with or without cause and without prior notice. I understand that no representative of the City of Bluffton has the authority to make any assurance to the contrary. In addition, I understand that the City of Bluffton utilizes the national E-Verify system to confirm my employment eligibility.
I attest with my signature below that I have given to the City of Bluffton true and complete information on this application. No requested information has been concealed. I authorize the City of Bluffton to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for denial of employment or immediate dismissal.
Date*
Date
Applicant Digital Signature*
Information Consent*
1. I consent to the City of Bluffton, Indiana storing my submitted information so they can respond to my inquiry.

Leave This Blank:

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

This field is not part of the form submission.
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