PERSONAL

Last Name:

First Name:

Middle Name:

DOB:

Address:

*Daytime Phone:

City:

Evening Phone:

Social Security #:

Email address:

Cell Phone:

Number of hours you plan to volunteer for:

hours per week month

AVAILIBILITY (Please list times available)

Monday:

Friday:

Tuesday:

Saturday:

Wednesday:

Sunday:

Thursday:

Special Circumstances:

EMPLOYMENT HISTORY

Employer Name (most recent first) and address:

Telephone:

Name of Supervisor:

Dates Employed:

From

Job Title:

May we contact this employer?

Yes No

Description of Duties:

Reason for leaving:

Employer Name (most recent first) and address:

Telephone:

Name of Supervisor:

Dates Employed:

From

Job Title:

May we contact this employer?

Yes No

Description of Duties:

Reason for leaving:

Employer Name (most recent first) and address:

Telephone:

Name of Supervisor:

Dates Employed:

From

Job Title:

May we contact this employer?

Yes No

Description of Duties:

Reason for leaving:

EDUCATIONAL HISTORY

Degree and Graduation Date or # of years completed

College/University/Technical/Vocational

School Name and Location

Degree and Graduation Date or # of years completed

Other Training/Courses

VOLUNTEER EXPERIENCE

Agency/Organization and Address:

Telephone:

Name of Supervisor:

Dates Volunteered

May we contact this agency:

Yes No

From

Job Title and Duties:

Agency/Organization and Address:

Telephone:

Name of Supervisor:

Dates Volunteered

May we contact this agency:

Yes No

From

Job Title and Duties:

BACKGROUND

*Do you have a valid driver’s license? Yes No

If yes, state and license #:

*Available car? Yes No

If yes, name of insurance company:

* Do you have any physical or mental conditions(s) which would limit your ability to participate in activities with Blue Earth County Community Corrections:

Yes No

If yes, please explain (limitation(s), activity restrictions, etc.)

A physical or mental condition(s) does not disqualify a volunteer. This data is required to determine how to accommodate any special needs.

*Have you ever been convicted of a criminal offense (including petty misdemeanors) or major traffic offense (misdemeanor or greater)?

Yes No

(Report all convictions past and present. (Convictions may not automatically disqualify you.)

If yes, what was your offense:

Date convicted: mm/dd/yyyy

End date of probation/parole or court jurisdiction: mm/dd/yyyy

*Are you now or have you ever been placed on probation or participated in a diversion program?

Yes No

If yes, please explain:

*Has any member of your family, a friend or acquaintance, ever been supervised on probation or diversion by this agency?

Yes No

If yes, please explain:

*Are you currently involved in a court matter in Minnesota or any other jurisdiction?

Yes No

If yes, please explain:

*Do you have any close friend or family member under any type of court jurisdiction, and/or in any correctional/placement/institution/facility?

Yes No (This will not disqualify you.)

If yes, please list name(s) and relationships:

List where you have lived the past five (5) years other than Blue Earth County:

*Have you ever been asked to resign or been terminated by an employer or a volunteer training program?

Yes No

If yes, please explain:

Records checks will be done on all volunteer applicants. A conviction does not disqualify a volunteer. It is generally necessary for a person to have made a satisfactory community adjustment for at least one year and/or subsequent completion of probation before acceptance is considered.

School Name:

School Address:

Internship Advisor:

Advisor’s Phone:

* REFERENCES

Name

Address

Telephone
xxx-xxx-xxxx

Relationship

Years Known