V O L U N T E E R A P P L I C A T I O N
Prospective volunteers will receive consideration without discrimination because of race, creed,
color, sex, age, national origin or disability.
P R E F E R R E D A R E A S O F I N V O L V E M E N T
___ Anti-Tobacco Program
___ Asthma Program
___ Asthma Walk (annual event)
___ Clean Air Program
___ Clerical/Office Work
___ Public Relations
___ Speakers Bureau
___ Health Fairs
___ Website/Data Entry
___ Other: _______________________
P E R S O N A L
Date:
Last Name First Name Middle
Street Address Home Phone
( )
City, State, Zip Cell Phone
( )
Email Work Phone
( )
Social Security Number Emergency Phone
( )
Have you ever worked or volunteered with us or another Lung Association?
Yes No If yes, month and year: _____________________________
Location: ________________________________________
When will you be available to start volunteering: ________________________________
Best times: _____________________________________________________________
Hours: ________________________ Days: _________________________________
Frequency preferred:
Hours per week: ____________________ Hours per month: _____________________
Other: _________________________________________________________________
E D U C A T I O N
School Name & Location Course of Did you Name of Degree
of School Study graduate? or Diploma
College:
High School:
Other:
Volunteer Application
2
Membership in professional or civic organization, or clubs (exclude those which may
disclose your race, color, religion, or national origin):
Interests, talents, hobbies, and special skills:
E M P L O Y M E N T / V O L U N T E E R P O S I T I O N S
(Please give an accurate complete full-time and part-time employment record. Start
with present or most recent employer)
Company Name Telephone
( )
Address Employed (month and year)
________________________________________ ________________________
From: To:
Name of Supervisor Reason for Leaving:
Job title and a brief description of your work: ______________________________
__________________________________________________________________
Employment Volunteer Position
Company Name Telephone
( )
Address Employed (month and year)
________________________________________ ________________________
From: To:
Name of Supervisor Reason for Leaving:
Job title and a brief description of your work: ______________________________
__________________________________________________________________
Employment Volunteer Position
Company Name Telephone
( )
Address Employed (month and year)
________________________________________ ________________________
From: To:
Name of Supervisor Reason for Leaving:
Job title and a brief description of your work: ______________________________
__________________________________________________________________
Employment Volunteer Position
Volunteer Application
3
Company Name Telephone
( )
Address Employed (month and year)
________________________________________ ________________________
From: To:
Name of Supervisor Reason for Leaving:
Job title and a brief description of your work: ______________________________
__________________________________________________________________
Employment Volunteer Position
We may contact the corporations or people
DO NOT CONTACT
listed above unless you indicate those you Numbers(s): ________________
do not want us to contact. __________________________
Reason:
M I L I T A R Y
Complete this section if you served in the U.S. Armed Forces
Branch of service: ___________________________________________________
Describe your duties and any special training: _____________________________
__________________________________________________________________
Period of active duty (month and year): From: ____________ To: _____________
Rank at time of discharge and date: _____________________________________
Was your discharge honorable?: Yes No
R E F E R E N C E S
(List people who are familiar with your qualifications)
Name Address Phone Relationship
__________________ _________________ _______________ ___________
___
________________ ________________ _____________ _____________
________________ ________________ _____________ _____________
________________ ________________ _____________ _____________
Do you smoke? Yes No Do you have transportation? Yes No
Volunteer Application
4
O T H E R
The information requested is needed for a legally permissible reason including, without
limitation, a legitimate occupational qualification or business necessity. The Civil Rights Act
of 1964 prohibits discrimination in employment because of race, color, religion, sex, or
national origin. Federal law also prohibits discrimination on the basis of age with respect to
certain individuals. The laws of most states also prohibit some or all of the above types of
discrimination as well as some additional types such as discrimination based upon
ancestry, marital status, physical or mental disability.
1. Are you under 18 years of age? Yes No
If yes, please have your parent sign below.
2. How long have you lived at your present address? Years ___________
How long did you live at your previous address? Years ___________
3. State names of relatives and friends working (or volunteering) for us other than
your spouse: ____________________________________________________
4. Do you have physical disabilities that preclude you from performing certain jobs?
Yes No If yes, please describe limitation: ___________________
5. Have you ever been bonded? Yes No
If yes, with what employer?
6. Have you ever been convicted of a crime in the past 5 years, excluding
misdemeanors and summary offenses, which has not been annulled, expunged
or sealed by court? Yes No
Are you presently under indictment or otherwise formally charged with a felony?
Yes No
If you have answered yes to any of these questions, please describe in full,
Indicating the date, nature, and place of the offense and the sentence and
disposition (probation, suspended sentence, incarceration): _____________________
_______________________________________________________________________
7. Do you have a valid driver's license? Yes No
8. I hereby declare that the information provided by me in this application is true,
correct and complete to the best of my knowledge. I understand that any
misstatement or omission of fact on this application shall be considered cause for
dismissal. I authorize you to obtain an investigative report containing information
obtained through personal interviews with my employers (paid & volunteer),
school personnel, neighbors, friends and acquaintances. This report, if obtained,
may include information as to my character, general reputation, and personal
characteristics. I understand I have a right to make a written request within a
reasonable period to receive additional detailed information about the nature and
scope of any such investigation.
Signature: _________________________ Date: _______________________
Parent Signature: ___________________ Date: _______________________
1469 Park Ave, San Jose, CA 95126
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