Form Center

2. Completing the following information is optional. It is considered confidential. Do not include your name anywhere on this page. This information is used to assist staff in fulfilling City Council goals related to equity and diversity.
4. If you prefer not to fill out this form, click on the link below.
   Fire Department web page
6. Gender - choose all that apply:
   -- Select One --ManWomanTrans or transgender (please specify below)Another identity (please specify below)
10. Age category
    -- Select One --18-2122-3031-4041-5051-6061 & over
12. Please specify your race and/or ethnicity (please check all that apply):

    1. American Indian/Alaskan native
    2. Asian
    3. Black/African American
    4. Hispanic/Latino
    5. Native Hawaiian/Other Pacific Islander
    6. White
    7. Multi-racial (fill in the blank below)
    8. Other (fill in the blank below)
14. Race/Ethnicity - additional information from above
16. Person with a disability
    -- Select One --YesNo
18. Formal education completed
    -- Select One --Did not complete high schoolHigh school graduateCollege graduateM.A. degree or equivalent level graduate degreeM.D., Ph. D. degree or equivalent level graduate degreeOther (fill in the blank below)
20. Education - additional information from above
22. Language(s) you speak in addition to English:
24. How long have you lived in Dubuque?
26. How long has your family lived in the United States?
    -- Select One --First generation AmericanSecond generation AmericanThird generation AmericanOther (fill in the blank below)
28. Other - from above
30. Household income
    -- Select One --Less than $10,000$10,000 to $49,999$50,000 to $149,999$150,000 or more
32. Federal law prohibits discrimination on the basis of race, color, religion, disability, sex, or national origin, as well as discrimination on the basis of age against persons over the age of 40. Some state and city legislation prohibits discrimination on the basis of age, marital status, sexual preference, race, color, religion, sex, national origin, or any other basis prohibited by law.
Leave This Blank:


34. Submit

* indicates a required field