AMERICAN RED CROSS - DOC by wanghonghx



                           Volunteer Application
                     DSHR System Enrollment Application
      All information provided to the American Red Cross in this application is treated and maintained in a secure manner.

                       Heart of Texas Area Chapter
                       4224 Cobbs Drive Waco, TX 76710
                    Telephone: 254-776-8362 or 888-776-9226
                               Fax: 254-776-3489

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                                                    PLEASE READ CAREFULLY

Thank you for your interest in the American Red Cross. In order to have your application processed, you must
thoroughly answer all questions on the application form. Applications filled out incompletely will not be
considered. While we encourage you to attach a resume, please note that a resume will not substitute for completing any
portion of this application. All information will be treated confidentially.

American Red Cross, an Equal Opportunity Employer, considers applicants for all positions without regard to race, color, religion,
sex, age, national origin, disabled or veteran status, or other legally protected status.

                                     The Mission of the American Red Cross
        The American Red Cross is a humanitarian organization, led by volunteers, that provides relief to victims of disaster and
        helps people prevent, prepare for and respond to emergencies. It does this through services that are consistent with the
        congressional charter and the fundamental principles of the International Red Cross and the Red Crescent Movement.
         Af f irming our commitment to the Fundamental Principles of the International Red Cross and Red Crescent
        M ov ement, we pledge ourselv es to these Values:
        We exist to serv e others in need, independently and without discrimination, prov iding relief f or v ictims of disasters
        and helping people prev ent, prepare f or, and respond to emergencies.
             We act responsibly, ef f ectiv ely, and ef f iciently with resources entrusted to us, always seek ing to improv e.
                                                          HELP IN G OTHERS
            We are attentiv e and responsiv e to those we serv e, always listening to their needs and look ing f or ways to serv e
                                                    through existing or new initiativ es.
                                                                 RESP ECT
              We ack nowledge, respect, and support the rights and div ersity of each person in our organization and in the
                                                        communities we serv e.
                                                         VOLU N TARY SP IRIT
   We, as a f amily of donors, v olunteers, and staf f , search f or ways to prov ide hope to those we serv e while demonstrating
                                             compassion, generosity, and appreciation.

                                                     CO NTINUO US LE ARNING
       We seek , collectiv ely and indiv idually, to identif y, obtain, and maintain competencies and the awareness required f or
                                                              exceptional serv ice.

                            We act with honesty and demonstrate courage and accountability under pressure.

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                                                                                                                    Heart of Texas Area Chapter
                                             Circle only one area you are requesting to work:            Disaster * Service to Armed Forces * Administration
                 Health & Safety Instructor * Life Guard    *    Community Service * Board Member *     Bio Med * Other _______
Date                                Date of Birth                                     Age Group (14-18)          (19-24)       (25-64)       (65 and over)

Contact Information : All Volunteers must Complete Background check by visiting
Legal Last Name                                                         First                              (Preferred               Middle
Home Address                                                     Apt/Bldg             City                                 S tate              Zip Code
Business Address                                                 S uite               City                                 S tate              Zip Code

Home Phone                         Business Phone                     Cell Number                                               Email Address:

My preferred mailing address is: Home address                    Business address          DL#                    State         Expires       Class
Employer                                                                              Occupation

Address:                                               City                           S tate, Zip                          Phone with Area Code:

Experiences (include both paid and volunteer work experience, beginning with most recent)
   You may attach another sheet or resume.

Organization Name                                               Address                                                      Phone

From                  To                                        S upervisor’s Name/Title

Organization Name                                               Address                                                      Phone

From                To                                          S upervisor’s Name/Title

Current Licenses and Certifications (other than those received through the Red Cross)
Type                                                            Number                                  S tate                 Expiration Date

Type                                                            Number                                  S tate                 Expiration Date

Education (highest level achieved)
Institution Name                                                City/State                              Degree/Major          Date Attended

Language Skill Proficiencies
Language:                    S peak: High     M edium           Low       Read:     High     M ed        Low Write:         High      M ed        Low
Language:                    S peak: High     M edium           Low       Read:     High     M ed        Low Write:         High      M ed        Low

Skills (please check up to four from the list and write 1, 2, 3, 4 beside each choice)
Accounting                                   Driving                                 Journalism                                Teaching
Administrative Support                       Events Coordination                     M anagement                               Technical Writer
Communications                               Filing                                  Photography                               Volunteer Advisor
Computer Support                             Financial Consultant                    Project M anagement                       Other (specify)
Counseling                                   Fund Raising                            Public Relations
Data Entry                                   Graphic Design                          Public Speaking

Availability check below and write times beside the day:

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Monday AM          Tuesday AM   Wednesday AM   Thursday AM   Friday AM
Monday PM          Tuesday PM   Wednesday PM   Thursday PM   Friday PM

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  Previous Red Cross Experiences If you Answer YES to this question-COMPLETE the ATTACHED SHEET
  Have you ever worked as a Red Cross employee or volunteer?             If yes, please list the location, title, department, and dates and
  complete the attached sheet.       Dates:                                  Location:
  Title:                              Department:                                  Paid____ or Volunteer_____

  Do you give us permission to transfer your records to our Chapter?                      Please Circle YES           NO
  Have you ever held any Red Cross certification?           (If yes, complete attached sheet.)

  A “yes” answer to the following italicized questions does not necessarily disqualify an applicant .
   I verify that I have not received any court ordered penalty (e.g. conviction, probation, deferred adjudication, etc.)
  for a crime within the last seven (7) years.

        I check this box as endorsement of my agreeance, in lieu of my signature. Date:__________

  I verify that I have received a court ordered penalty (e.g. conviction, probation, deferred adjudication, etc.) for a
  crime within the last seven (7) years. Please list details and dates:

      I check this box as endorsement of my agreeance, in lieu of my signature. Date:__________
       Offense:                                                          Status:

                                     Applications without one of the above boxes marked, cannot be accepted
   Have you previously used any other names besides what is provided above?                      No          Yes If yes, please specify

 I do hereby give the American Red Cross permission to inquire into my educational background, references, driving record, pol ice
 records, employment, and/or volunteer history. I further give permission to the holder of any such records to release the same to the
 American Red Cross.

 I do hereby hold the American Red Cross harmless from any liability, whether civil or criminal, that may arise as a result of the
 release of this information about me. I further hold harmless any individual, agency, business, or corporation that provides information
 or documents to the above-named American Red Cross unit. I understand that the American Red Cross will use this information as part
 of its verification of my volunteer application and periodically for evaluation purposes.

 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
false statements of any kind or omission of facts called for on this application are a basis for dismissal of volunteer status regardless when
they are discovered.

I understand that any volunteer status is for an indefinite duration, unless otherwise specified in writing, and is at-will, which means that
either I or the American Red Cross may terminate my volunteer status at any time with or without notice or cause. I further understand
that neither the policies, rules, regulations of volunteer service, application for volunteering, nor anything said during the interview
process shall be deemed to constitute the terms of any implied employment contract.

 Signature: ________________________________________Date: __________________________________

                                          Consent of Parent/Guardian for Applicant Under Age 18

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Name: ____________________________________________ Relationship: _________________________________

Signature: _________________________________________ Date:_________________________________

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                            CONFIDENTAL INFORMATION
                   Emergency Contact/Medical Information Release Form

       Name: _______________________________                            Date Of Birth: ________________

       Home Phone: ____________________ Cell #: ________________________

       Address (if different from applicant) __________________________________________________

        City ____________________________            State ___________________ Zip _____________

       Doctor: _____________________________ Phone Number: __________________________

       Hospital Preference: _______________________________

       List any allergies and medical conditions:

       Date of last tetanus shot:

                            EMERGENCY CONTACT INFORMATION

Name: __________________________________                 Relationship:____________________________

Address:__________________________________ City: _____________________ St:______ Zip: _______

Cell Phone: _______________________ Home Phone: _______________ Work Phone: _______________

Other: _____________________

       I authorize the American Red Cross paid or volunteer staff to secure medical and/or transportation as necessary
       in their judgment. I assume responsibility for any medical and/or transportation costs incurred in route to and at a
       medical facility.

 _____________________________                      ______________

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Signature         Date

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Name: __________________________________

                                           Work Preference

Please rate 1, 2, and 3 etc your job preference:

____         Sheltering                                      ____ Communication

____         Feeding                                         ____ Office Work

____         Logistics                                       ____   ERV Driver

____         Service to Armed Forces                         ____ Welfare Information

____        Health Services (_______) ____ Disaster Mental
                          Profession: RN, LVN, PA, Dr, etc              Profession: Psychologist, Psychiatrist, LPC, etc

____        Fund Raising                                     ____ In-Kind Donations

____        Warehousing/Supply                           ____       Transportation (CDL)

____        Switchboard                                  ____       Government Liaison

____         Other: ___________________

SHIFT PREFERENCE:                               DAYS AVAILABLE:

_ 7a-3p __ 3p-11p __ 11p-7p                  __ Sun __Mon __Tue __Wed __Thur __Fri ___Sat

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                                                                                                 Invitation for Self-Identification
                                                                                                                   For Applicants

The American Red Cross is an equal opportunity employer. In recognition of its responsibility to its paid and volunteer staff, and the
community it serves, the Red Cross affirms its policy to assure fair and equal treatment in all of its employment practices for all persons. We
consider applicants for all positions without regard to race, color, religion, sex, age, national origin, disabled or veteran status, or other legally
protected status. To help us track our organizational success, we ask your assistance in filling out this voluntary self-identification form. In
addition to our internal tracking, the Red Cross must meet government record-keeping and reporting requirements. Completion of this form is
voluntary, and will not affect your application for employment or employment with the Red Cross. This information will be kept in confidence
and will not accompany your application to the prospective supervisors. Please contact the EEO Office if you have any questions.

       Name                                                                                               Date

       Position Volunteering for (Please Circle only one choice)

       Disaster      Services to Armed Forces          Health and Safety Instructor         Life Guard       Bio Med

       Administration Clerical Administration Professional Community Service                         Other:________________

Check all that apply:
   Female                       Male                                           Age at time of application: ____________

Would you like to self-identify your race/ethnicity?               Yes           No

If yes, please continue to the next question.

Are you Hispanic or Latino?
   Yes, I am Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin regardless of race

If and only if you are not Hispanic or Latino, please choose one of the following categories.

   White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North

   Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa

  Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii,
Guam, Samoa, or other Pacific Islands

   Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian Subcontinent, including, for example, Cambodia, Chin a, India, Japan, Korea, Pakistan, Philippines, Vietnam or Thailand

  American Indian or Alaskan Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North
and South America (including Central America), and who maintain tribal affiliation or community attachment

   Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races

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The American Red Cross is a not-for-profit charitable organization dedicated to providing services to those in need. The Red Cross has
traditionally demanded and received the highest ethical performance from its employees and volunteers. In an effort to maintain the
high standard of conduct expected and deserved by the American public and to enable the organization to continue to offer its services,
the American Red Cross operates under the Code of Business Ethics and Conduct outlined below. All employees and volunteers are
required to sign the Code of Business Ethics and Conduct form certifying that, in delivering Red Cross services and in all other Red
Cross activities, they shall meet the following standards of conduct:
        Compliance Requirements. All employees and volunteers are required to comply with applicable federal, state and local
         laws and regulations and with American Red Cross corporate policies and regu lations.

        Actions Prohibited by the Code of Business Ethics and Conduct. No employee or volunteer shall engage in the following

         a. Personal Use. Authorize the use of or use for the benefit or advantage of any person, the name, emblem, endors ement,
            services or property of the American Red Cross, except in conformance with American Red Cross policy.

         b.   Financial Advantage. Accept or seek on behalf of or any other person, any financial advantage or gain of other than
              nominal value offered as a result of the employee’s or volunteer’s affiliation with the American Red Cross.

         c. Red Cross Affiliation. Publicly use any American Red Cross affiliation in connection with the promotion of partisan
             politics, religious matters or positions on any issue not in conformity with the official position of the American Red

         d.   Confidentiality. Disclose any confidential American Red Cross information that is available solely as a result of the
              employee’s or volunteer's affiliation with the American Red Cross to any person not
              authorized to receive such information, or use to the disadvantage of the American Red Cross any such
              confidential information, without the express authorization of the American Red Cross.

         e.   Improper Influence. Knowingly take any action or make any statement intended to influence the conduct of the American
              Red Cross in such a way as to confer any financial benefit on any person, corporation or entity in which the individual has
              a significant interest or affiliation.

         f.   Conflict of Interest. Operate or act in a manner that creates a conflict or appears to create a conflict with the interests of
              the American Red Cross and any organization in which the individual has a personal, business or financial interest. In the
              event there is a conflict, the American Red Cross has a structured conflict of interest process. First, the individual shall
              disclose such conflict of interest to the chairman of the board or the chief executive officer of the individual’s Red Cross
              unit or the general counsel of the American Red Cross, as applicable. Next, a decision will be made about the conflict of
              interest, and, where required, the individual may be required to recuse or absent himself or herself during deliberations,
              decisions and/or voting in connection with the matter.

         g.    Retaliation. Retaliate against any employee or volunteer who seeks advice from, raises a concern with or makes a
              complaint to a supervisor or other member of management, the ombudsman, the Concern Connection Line, the Biomedical
              Regulatory Hotline or any other whistleblower program, about fraud, waste, abuse, policy violations, discrimination, illegal
              conduct, unethical conduct, unsafe conduct or any other misconduct by the organization, its employees or volunteers .

         h.   Contrary to the Best Interest of the Red Cross. Operate or act in any manner that is contrary to the best interest of the
              American Red Cross.

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    Ombudsman Program – Informal Dispute Resolution. The American Red Cross has an organizational ombudsman designated
        as the neutral or impartial dispute resolution practitioner whose major function is to provide confidential and informal
        assistance to the many constituents with concerns or complaints about the Red Cross. The constituents who seek the
        ombudsman’s services are internal stakeholders, such as employees and volunteers, and external stakeholders, such as Red
        Cross clients, donors, suppliers, vendors and the public at large. The ombudsman provides a voluntary, confidential and
        informal process to facilitate fair and equitable resolutions and explore a range of alternatives or options to resolve the
        problems. If a formal investigation is what the individual seeks, referrals to the whistleblower hotlines may be appropriate.

        Investigations, Compliance and Ethics – Formal Dispute Resolution. Distinguishing from the actions of the ombudsman, the
         Office of the General Counsel and the Office of Investigations, Compliance and Ethics (IC&E) conduct formal investigations
         into allegations of fraud, waste, abuse, Red Cross policy violations, illegal or unethical conduct or other improprieties regarding
         the Red Cross. Usually, the allegations arise from whistleblower complaints of Red Cross employees and volunteers seeking
         formal review or investigations of their allegations of wrongdoing.

        Whistleblower Hotline Programs. The American Red Cross encourages open communications. All employees and volunteers
         are encouraged to bring any concerns they have regarding the organization or its employees and volunteers to their direct
         supervisor. If individuals seek an informal and confidential resolution, the ombudsman may be the appropriate choice. If a
         formal IC&E investigation is sought, the hotlines described below are the appropriate choice.

         If an employee or volunteer suspects or knows about misappropriation, fraud, waste, abuse, Red Cross policy violations, illegal
         or unethical conduct, unsafe conduct or any other misconduct by the organization or its employees or volunteers, that
         individual should alert his or her supervisor or other member of local management. In those cases where an employee or
         volunteer is not comfortable telling his or her supervisor or local management, the employee or volunteer may contact the
         Concern Connection Line at 1-888-309-9679. For concerns about the collection, manufacturing, processing, distribution or
         utilization of blood or blood components (e.g., violations of FDA or OSHA regulations, falsification, quality failures, training,
         Biomedical Services computer and equipment issues), an employee or volunteer who is not comfortable with contacting his or
         her supervisor or local management may contact the Biomedical Regulatory Hotline at 1-800-741-4738.


I, ______________________________________________, certify that I have read and understand the Code of Business Ethics
           Applicant Name
 and Conduct of the American Red Cross and agree to comply with it, as well as applicable laws that impact the organization, at all
times. I affirm that, except as listed below, I have no personal, business or financial interest that conflicts, or appears to conflict,
with the best interests of the American Red Cross . I agree to discuss any conflicts listed below with the chairman of the board or
the chief executive officer of my unit or the general counsel of the American Red Cross and to refrain from participating in any
discussions, deliberations, decisions and/or voting related to the matter presenting the conflict until such time as it is determined by
the Red Cross that the conflict is mitigated or otherwise resolved .

Describe any potential conflicts:

At any time during the term of my affiliation with the American Red Cross, should an actual or potential conflict of interest arise between
my personal, business or financial interests and the interests of the Red Cross, I agree to: (1) disclose promptly the actual or potential
conflict to the chairman of the board or the chief executive officer of my Red Cross unit or the general counsel of the American Red
Cross; and (2) until the Red Cross approves actions to mitigate or otherwise resolve the conflict; refrain from participating in any
discussions, deliberations, decisions and/or voting
 related to the conflict of interest.

                                             Statement MUST be signed by all applicants.

Signature: ____________________________________________ Date: _______________________

Print Name: __________________________________________

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Rev. January 2007

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                                            CONFIDENTIAL INFORMATION AND
                                         INTELLECTUAL PROPERTY AGREEMENT

                                                      For All Volunteers

This Confidential Information and Intellectual Property Agreement (“Agreement”) is made as of the date of signature below
(“Effective Date”), by and between THE AMERICAN NATIONAL RED CROSS, including all chartered units (“Red Cross”),
and the undersigned (“I,” “me” or “my”).

Reasons for Agreement

I desire to volunteer or to continue to volunteer with the Red Cross. I acknowledge that I may, in
the course of my service to the Red Cross (“Volunteer Service”), have access to or create (alone or with
others) confidential and/or proprietary information and intellectual property that is of value to Red Cross. I
understand that this makes my position one of trust and confidence. I understand Red Cross’ need to
limit disclosure and use of confidential and/or proprietary information and intellectual property. I
understand that all restrictions are for the purpose of enabling Red Cross to fulfill its humanitarian
mission, to maintain donors, customers and clients, to develop and maintain new or unique products and
processes, to protect the integrity and future of Red Cross and to protect the employment and volunteer
opportunities of the Red Cross.

THEREFORE, I agree to the following:

1. Definitions.

“Confidential Information” shall include but not be limited to:
(i) information relating to Red Cross’ financial, regulatory, personnel or operational matters,
(ii) information relating to Red Cross clients, customers, beneficiaries, suppliers, donors (blood and financial), employees,
volunteers, sponsors or business associates and partners,
(iii) trade secrets, know-how, inventions, discoveries, techniques, processes, methods, formulae, ideas, technical data
and specifications, testing methods, research and development activities, computer programs and designs,
(iv) contracts, product plans, sales and marketing plans, business plans and
(v) all information not generally known outside of Red Cross regarding Red Cross and its business, regardless of whether
such information is in written, oral, electronic, digital or other form and regardless of whether the information originates
from Red Cross or Red Cross’ agents.

“Intellectual Property” shall include but not be limited to:
(i) all inventions, discoveries, techniques, processes, methods, formulae, ideas, technical data and specifications, testing
methods, research and development activities, computer programs and designs (including improvements and
enhancements and regardless of patentability),
(ii) trade secrets and know-how,
(iii) all copyrightable material that is conceived, developed, or made by me, alone or with others,
(iv) trademarks and service marks and
(v) all other intellectual property.

Intellectual Property shall include any intellectual property created by me:
(i) in the course of Volunteer Service or using Red Cross time, equipment, information or materials, and
(ii) within one (1) year after termination of Volunteer Service and relating directly to work done during Volunteer Service.

Intellectual Property may be in any form, including but not limited to written, oral, electronic, digital or other form.

2. Obligation of Confidentiality.

Except as may be required for the performance of my duties during Volunteer Service, or unless specifically authorized in
writing by Red Cross, I shall not use or disclose, for my or for others’ benefit, either during or after Volunteer Service, any
Confidential Information.

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3. Disclosure and Ownership of Intellectual Property.

 I (i) shall promptly and fully disclose to Red Cross any and all Intellectual Property, (ii) agree that all Intellectual Property
shall be owned by Red Cross, (iii) agree to and do hereby assign, transfer and convey to Red Cross the entire right, title
and interest in and to all Intellectual Property, (iv) will execute and deliver any and all doc uments, take all actions and
render any and all assistance reasonably requested by Red Cross, during or at any time after Volunteer Service, to
establish Red Cross’ ownership of, or to enable Red Cross to obtain patents to or register copyrights of, any Intellectual
Property, and (v) acknowledge that all Intellectual Property that is copyrightable subject matter and that qualifies as a
"work made for hire" shall be automatically owned by Red Cross. In the event Red Cross is unable for any reason
whatsoever to secure my signature to any document required to apply for or execute any patent, copyright, or other
applications with respect to Intellectual Property, I hereby irrevocably appoint Red Cross and its authorized officers and
agents as my agents and attorneys-in-fact to execute and file any such application and to do all other acts to further the
prosecution and issuance of patents, copyrights, or other rights with respect to Intellectual Property with the same legal
force and effect as if executed by me.

As a reminder, Intellectual Property shall only include intellectual property created by me (i) in the course of Volunteer
Service or using Red Cross time, equipment, information or materials, and (ii) within one (1) year after termination of
Volunteer Service and relating directly to work done during Volunteer Service.

4. Ownership and Return of Material

All materials, including but not limited to business information, files, research, records, memoranda, books, lists,
computer disks, hardware, software, cell phones and other wireless devices, documents, drawings, models, apparatus,
sketches, designs and any other embodiment of Confidential Information or Intellectual Property received by me during
Volunteer Service, and any tangible embodiments of such materials created by me, alone or with others, whether
confidential or not, are the property of Red Cross. I shall return to Red Cross all such materials, including copies thereof,
in my possession or under my control upon termination of Volunteer Service for whatever reason or upon the request of
Red Cross. The return of such materials shall take place within twenty -four (24) hours of notice of termination or upon
request of Red Cross, whichever comes first.

5. Survival of Obligations and Enforcement

The obligations that I have under this Agreement shall survive the termination of Volunteer Service, regardless of the
reasons or method of termination. I agree that Red Cross shall be entitled to recover from me all attorneys’ fees incurred
in enforcing Red Cross’ rights under this Agreement.

I represent that the above restrictions are necessary to protect Red Cross’ legitimate interests, and that these restrictions
will not prevent me from earning a livelihood.


_______________________________________                                ________________________
Printed Name                                                                Date

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Signature Volunteer

Rev 03/05

                                                               INFORMATION RELEASE

I give to the American Red Cross, its designees, agents and assigns, unlimited permission to use, publish and
republish in any form or media, information about me and reproductions of my likeness (photographic or
otherwise) and my voice, with or without identification to me by name.

Name of person (VOLUNTEER) photographed, recorded or interviewed (please print):


Age (if minor): ____________ (See Below)

Signature: ________________________________________        Date: ___________________


  ___________________________                               ___________
  Signature                                                 Date

 ____________________________ __________________
 Printed Name                 Relationship

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                                                                 Intake Sheet Volunteer Copy


This sheet lets you know what information you’ll need to provide in order to process your background

Everyone will need to know their names, addresses, e-mail addresses (if you have one), and
telephone numbers as well as:

        1) Social security number or other government ID
        2) Driver’s license number (if you have one)

You’ll also need to know your unit of affiliation, which your unit administrator will provide if you are
selected for the position.

                     Heart of Texas Area Chapter
If you are applying for a job or volunteer position, your unit of affiliation may require additional information. If your uni t
administrator has checked off any of the boxes below, you will be required to provide information about that aspect of your
background in order to process the check.

                  xx BASIC information: Full Name, Current Address, SSN, Date of Birth, and Drivers
                       License Number. If you are currently residing in Puerto Rico, you must provide your
                       mother’s maiden name.

                  xx Previous Employment and/or Volunteer experience. Please be
                     prepared to provide the name, address, and phone number of all
                     employment and/or volunteer experiences you have had for the past 7
                     years. Please also include a contact name.
                  xx Education. Please provide your HIGHEST level of education. You will
                     need to provide your School’s name, City, State, Zip Code, Phone
                     number, Start & End date, Major and Degree Earned.
                  xx Professional License. Please provide the license number, type, and
                     state of issuance and the name of the issuing agency or entity. (If


Once you’ve gathered the information you need, please go to this secure website:

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Para información ón en espa ñol, visite o escribe a la FTC Consumer
Response Center, 600 Pennsylvania Ave., NW, room 130-A, Washington, DC 20580.

                     A Summary of Your Rights under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness and privacy of
information in the files of consumer reporting agencies. There are many types of consumer reporting
agencies, including credit bureaus and specialty agencies (such as agencies that sell information
about check-writing histories, medical records and rental history records). Here is a summary of your
major rights under the FCR.

For more information, including information about additional rights, go to or write--Federal Trade Commission, Consumer Response Center, 600
Pennsylvania Ave. N.W., Room 130-A, Washington, DC 20580.

                You must be told if information in your file has been used against you. Anyone
                 who uses a credit report or another type of consumer report to deny your application for
                 credit, insurance or employment—or to take another adverse action against you—must
                 tell you and must give you the name, address and phone number of the agency that
                 provided the information.

                You have the right to know what is in your file. You may request and obtain all the
                 information about you in the files of a consumer reporting agency (your “file disclosure”).
                 You will be required to provide proper identification, which may include your social
                 security number. In many cases, the disclosure will be free. You are entitled to a free file
                 disclosure if:
                       A person has taken adverse action against you because of information in your
                        credit report.
                       You are on public assistance.
                       You are the victim of identity theft and place a fraud alert in your file.
                       Your file contains inaccurate information as a result of fraud.
                       You are unemployed but expect to apply for employment within 60 days.

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In addition, by September 2005, all consumers will be entitled to one free disclosure every 12 months
upon request from each nationwide credit bureau and from nationwide specialty consumer reporting
agencies. See for additional information

                You have the right to ask for a credit score. Credit scores are numerical summaries
                 of your creditworthiness based on information from credit bureaus. You may request a
                 credit score from consumer reporting agencies that create scores or distribute scores
                 used in residential real property loans, but you will have to pay for it. In some mortgage
                 transactions, you will receive credit score information for free from the mortgage lender.
                You have the right to dispute incomplete or inaccurate information. If you identify
                 information in your file that is incomplete or inaccurate and report it to the consumer
                 reporting agency, the agency must investigate unless your dispute is frivolous. See
        for an explanation of dispute procedures.
                Consumer reporting agencies must correct or delete inaccurate, incomplete or
                 unverifiable information. Inaccurate, incomplete or unverifiable information must be
                 removed or corrected, usually within 30 days. However, a consumer reporting agency
                 may continue to report information it has verified as accurate.
                Access to your file is limited. A consumer reporting agency may provide information
                 about you only to people with a valid need—usually to consider an application with a
                 creditor, insurer, employer, landlord or other business. The FCRA specifies those with a
                 valid need for access.
                Consumer reporting agencies may not report outdated negative information. In
                 most cases, a consumer reporting agency may not report negative information that is
                 more than seven years old or bankruptcies that are more than 10 years old.
                You must give your consent for reports to be provided to employers. A consumer
                 reporting agency may not give out information about you to your employer or a potential
                 employer, without your written consent given to the employer. Written consent generally is
                 not required in the trucking industry. For more information, go to
                You may limit ‘prescreened” offers of credit and insurance you get based on
                 information in your credit report. Unsolicited “prescreened” offers for credit and
                 insurance must include a toll-free number you can call if you choose to remove your name
                 and address from the lists these offers are based on. You may opt out by calling the
                 nationwide credit bureau.
                You may seek damages from violators. If a consumer reporting agency or, in some
                 cases, a user of consumer reports or a furnisher of information to a consumer reporting
                 agency violates the FCRA, you may be able to sue in state or federal court.
                Identity theft victims and active duty military personnel have additional rights. For
                 more information, visit

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States may enforce the FCRA and many states have their own consumer reporting laws. In
some cases, you may have more rights under state law. For more information, contact your
state or local consumer protection agency or your state Attorney General. Federal enforcers

          TYPE OF BUSINESS:                                    CONTACT:

          Consumer reporting agencies, creditors and           Federal Trade Commission:
          others not listed below                              Consumer Response Center - FCRA
                                                               Washington, DC 20580
          National banks, federal branches/agencies of         Office of the Comptroller of the Currency
          foreign banks (word "National" or initials "N.A."    Compliance Management, Mail Stop 6-6
          appear in or after bank's name)                      Washington, DC 20219
          Federal Reserve System member banks (except          Federal Reserve Board
          national banks, and                                  Division of Consumer & Community Affairs
          federal branches/agencies of foreign banks)          Washington, DC 20551

          Savings associations and federally chartered         Office of Thrift Supervision
          savings banks (word "Federal" or initials "F.S.B."   Consumer Complaints
          appear in federal institution's name)                Washington, DC 20552
          Federal credit unions (words "Federal Credit         National Credit Union Administration
          Union" appear in institution's name)                 1775 Duke Street
                                                               Alexandria, VA 22314
          State-chartered banks that are not members of        Federal Deposit Insurance Corporation
          the Federal Reserve System                           Consumer Response Center, 2345 Grand Avenue,
                                                               Suite 100, Kansas City, Missouri 64108-2638
          Air, surface, or rail common carriers regulated by   Department of Transportation , Office of Financial
          former Civil Aeronautics Board or Interstate         Management
          Commerce Commission                                  Washington, DC 20590
          Activities subject to the Packers and Stockyards     Department of Agriculture
          Act, 1921                                            Office of Deputy Administrator - GIPSA
                                                               Washington, DC 20250

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Complete information as thoroughly as possible. Introduction To Disaster Services, CPR and First Aid certificates are
required for all DSHR system members. Indicate mo/da/yr in which course was most recently completed.

                         course name                                                                           month/day/year
     1. introduction to disaster services
     2. cpr
     3. first aid

                                           LIFE EXPERIENCE INFORMATION
(note any skills, knowledge, non-red cross training, management, supervisor and life experiences that assist in meeting
competency criteria as listed in the competency criteria, add additional pages as needed

Disaster Relief Operation History                                                                              Disaster Operation Group And
(complete with information regarding any disaster assignments on which you have served and which               Activity Preference
will substantiate your disaster history, particularly for your group and activity preferences. refer to your   Discuss with your unit’s disaster services rep,
unit disaster services representative to clarify DR numbers, operation n ames and positions in which you       the disaster operation activities which you
served. write local if no rd# was assigned .                                                                   meet the competency criteria. complete in
                                                                                                               order of preference. use as listed in
                                                                                                               competency criteria.

DR #             operation name          date               position         # days          evaluation        group           activity         position
received                                 mm/dd/yyy

endorsement---------- unit of affiliation
I endorse this individual as a member of DSHR system and verify that the individual meets the baseline criteria for membership and meets the

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competency criteria for the group and activities designated.
Print Name:                                                    Title:

Signature:                                                     Date:

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