Name ___________________________________________ Date_____________

Street or PO Box City, State ___________________________________________________________

Work Phone _____________________ Home Phone__________________________

Cell Phone E-mail ________________________________

Education

Highest Level of education? ______________________

Are you currently a student?  Yes__ No__

School/University/Program (if applicable) _______________________________________

Employment

Current Employer (if applicable) _______________________________________________

Position/Title _______________________________________________

Dates of Employment (starting, ending)__________________________

Address _____________________________________________________________________________________

_____________________________________________________________________________________

Would you like to keep your employer abreast of your volunteer service and achievement? Yes__ No__

Special training, skills or hobbies__________________________________________________________

What experiences have you had that may prepare you to work as a volunteer in a library/historical society/museum

 

Why do you want to volunteer or what do you hope to gain from this volunteer experience?

 

Have you ever been convicted of a crime? Yes__ No__

If yes, please explain the nature of the crime and the date of the conviction and disposition. Conviction of a crime is not an automatic disqualification for volunteer work.  ________________________________________________________________________________

_____________________________________________________________________________________

REFERENCES: Please list three people who know you well and can attest to your character, skills and dependability. Include your current or last employer, if applicable.

Name                Relationship to You                      Phone                             Length of relationship

1. _____________________________________________________________________________________

2.

_____________________________________________________________________________________

3. _____________________________________________________________________________________

Please read the following carefully before signing this application:

By agreeing below, I give the ICRC permission to check the references listed. I certify that the facts set forth in the application are true to the best of my knowledge. I understand that any falsification, misrepresentation, or concealment of information in this application will disqualify me from further consideration. The ICRC shall not be liable in any respect if my application is denied or terminated. I understand that the ICRC reserves the right to screen volunteers/interns, to accept or reject any application, and to place applicants in specific locations and positions based on the needs of the ICRC. I understand that I will not be paid for my services as a volunteer/intern, and I am giving my time freely to the ICRC. I understand that the ICRC may terminate my volunteer service at any time and for any reason.

I agree to the terms and conditions.

 

Signature _____________________________________