Volunteer Application

Applicant Information
Full Name:
Last First M.I.

Date:

Address:
Street Address Apartment/Unit #

City

State

ZIP Code

Phone: Date of Birth: T-Shirt Size:

YES NO

Email Social Security No.: Email:

YES

NO

Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?

Background
Have you ever been charged with or convicted of the following:
YES NO

a) b)

Felony?
YES NO

Any crime involving a sexual offense, an assault or use of a weapon?

If you answered Yes to any of the above, please explain: __________________________________________________ __________________________________________________ Run a background check on me:
YES NO

LVNM Dollies have my permission to: By signing below, I affirm that I have answered all questions truthfully. I understand that if any portion of this application Is found to be intentionally false, I may be denied as a member of LVNM Dollies.

Your Signature: _______________________________________________ Date: ______________________________

References
Please list three professional references.
Full Name: Company: Address: Full Name: Company: Address: Full Name: Company: Address: Relationship: Phone: Relationship: Phone: Relationship: Phone:

Employment
Company: Address: Job Title: Responsibilities: From: To: Reason for Leaving:
YES NO

Phone: Supervisor: Starting Salary:$ Ending Salary:$

May we contact your previous supervisor for a reference?

Volunteer Service
Why are you interested in becoming a member of LVNM Dollies?

How did you hear about LVNM Dollies? Have you volunteered for other organizations? (If you checked yes, please continue below) Organization Name: Type of volunteer service: Describe any work or personal experience you think might be relevant to our program:

( ) Word of Mouth ( ) Event ( ) Facebook ( ) Other ___________ Yes __________ No ________________________________________________________ ________________________________________________________

________________________________________________________ ________________________________________________________ ________________________________________________________

Do you have any hobbies or special talents?

________________________________________________________ ________________________________________________________

Disclaimer and Signature

Release for Publication During your time as a LVNM Dollie, there will be occasions when you may be photographed and/or videotaped by other members of the group, and/or media. We request permission for your participation. By initialing below, you may choose to grant or deny LVNM Dollies permission to use photographs or videotape yourself, alone or in groups, in newspaper articles, newsletters, online, brochures, scrapbook, videos and photo albums for use in public understanding and support of the LVNM Dollies. By granting permission below, you hereby release and hold harmless LVNM Dollies from any claims, judgments or demands which may arise from the use of the above referenced photographs and/or videotapes.

__________ YES, I give permission to be photographed and/or videotaped for publication.

Initial

OR

__________ NO, I deny consent to be photographed and/or videotaped for publication. Initial

I certify that my answers are true and complete to the best of my knowledge. If this application leads to being accepted as a member of LVNM Dollies, I understand that false or misleading information in my application or interview may result in my release of the group. I also understand that if selected, I will be placed on a 90 day probationary period. If for any reason I do not fulfill my duties as a LVNM Dollie, I do understand that I may be released. In addition, I am responsible for paying my $25.00 (non-refundable) annual membership fee upon approval of my membership.

Signature:

Date:

Once your application is completed, please mail or email to: LVNM Dollies PO Box 3514 Las Vegas, NM 87701 lasvegasnm_dollies@yahoo.com

LVNM Dollies USE ONLY Received _______________ Contacted_______________ Meeting________________ Fee_____________ Background Check___________ Start___________________ Expire____________________ Reason ________________________________________________________