Volunteer Application

Name	Social Security No.
Mailing Address
Business Address
Area Code/Home Phone	Area Code Business Phone
Sex
Marital Status
Date of Birth
Present Occupation	Working Hours	Does Job Require Travel
Highest Grade Level or Education Completed	Degree Acquired
Other Training

Special Qualifications (Skills, Hobbies, Interests, Talents, Inc,)

Previous experience that would help in volunteer work:

Type of Volunteer Service that interests you (Counseling, Clerical, Administrative, Etc.)

How much time can you volunteer?	Hours (Weekly or Monthly)	AM	PM
How long can you commit yourself as a volunteer?	1-3 months
3-6 months
Longer
Do you have a criminal record (juvenile or adult)?
References
Name	Address	Phone
I hereby certify that all statements made on this application are true.
Signature
Date

Assignment to be completed by appropriate authority.
1. Process Area
5. County
Department of Economic Opportunity
2. Process Unit
6. City
3. Section
7. Comparable Career Service Class
4. Subsection
8. Position Number	Budget Number
9. Previous Volunteer Service to DEO (Within Calendar Year)
From	To
From	To
From	To
From	To
10. Dates of This Assignment:	From	To
Part Time
Full Time
Hours Per Week
11. Type Volunteer Assignment	Regular Service	Occasional Service	Material Donor
12. Duties and Responsibilities, or Funds, Materials, Employment or Opportunities Provided.

13. Authorized Signature
Title	Date

DEO Form OPT 21 (2/01)

Department of Labor and Employment Security

J0JEM

1999-11-10

Jackie McGill

FDLES J&B OIT