Volunteer Application
For ACCORD Mediator Volunteers
Please Print Clearly.
Name: __________________________________________ Date: ________________________
Home Address: _________________________________________________________________
Home Phone: (____)____-_______ SSN:_________________ Sex:______________M_____F
Emergency Contact Person: ____________________ Phone: (____)____-______
Employer: ____________________________ Type of Organization: ___________
Position: _____________________________ Length of time employed: ________
Business Address: ____________________________________________________
Phone: (____) _____-______ May we contact you at work: ____________________
Email: ______________________________________________________________
EDUCATION HISTORY:
School Field of Study Degree Date
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EXPERIENCE:
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List Any Specific Qualifications/Skills you have that would be an asset to program:
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ADDITIONAL INFORMATION:
Have You Ever Been Convicted Of A Crime: ________ Explain:
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Why Do You Wish To Participate In This Program:
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How Did You Become Aware of ACCORD:
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REFERENCES:
Please List Three Non Related References.
1. Name: ______________________________ Relationship: _______________
Address: _______________________________ Phone:(____)____-_______
2. Name: ______________________________ Relationship: _______________
Address: _______________________________ Phone: (____) ____-_______
3. Name: ______________________________ Relationship: _______________
Address: _______________________________ Phone: (____) ____-_______
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Applicants Certification and Agreement
The criteria used in the selection of volunteers have been established to ensure that the individual
is able to meet the responsibilities of being a volunteer of ACCORD. No individual will be
rejected based on race, color, religious creed, national origin, sex, age or marital status.
I hereby certify that the facts set forth in this volunteer application are true and complete to the
best of my knowledge. I understand that if accepted as a volunteer, falsified statements on this
application shall be considered sufficient grounds for dismissal. I understand the information in
this application and that otherwise may be obtained will be used only for determining my
eligibility for volunteer service and will be kept confidential.
______________________________ _______________________
Signature of Applicant Date