Embassy Volunteer Information Request form

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* 1. Address

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. When is the best time to reach you at home by phone?

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* 3. List times you are available to volunteer

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* 4. List type of work you are interested in volunteering:

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* 5. Have you had previous volunteer experience?

Yes

If so, where and what was your task?

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* 6. Are you currently employed?

Yes

Retired

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* 7. If you are employed, please provide the following information.

Employer Name

Occupation/Title

Duties

Are you employed full-time or part-time?

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* 8. Emergency Contact Person

Name

Phone

Relationship

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* 9. Medical Information

Physician's Name

Phone

List any allergies, medical concerns and/or physical limitations

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* 10. Please list one reference.

Name

Address

Phone

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* 11. Have you ever been convicted of or pleaded guilty to a felony or misdemeanor, other than a minor traffic violation? (Conviction or plea will not necessarily disqualify an applicant.)

Yes

If yes, please explain

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* 12. By clicking the "I Agree" button below you understand this information may be disclosed to any party with legal and proper interest, and you release the organization from any liability whatsoever for supplying such information. You grant the agency permission to obtain information from references you have provided. You certify the statements made in this volunteer application are true and correct and have been given voluntarily. You understand misrepresentation of any information may result in termination of your volunteer involvement. You understand you are volunteering your time for personal reason. You understand that you will not be paid for your services as a volunteer and expect no compensation.

I Agree