Date: ______/______/______

Name:______________________________________________________________________________________

(Last) (First) (Middle) (Any other names you have been known by, e.g.- maiden)

Current Address and Previous for the Last 5 Years: (use additional paper if needed)

____________________________________________________________________________________

(Street Address) (City) (State) (ZIP Code)

____________________________________________________________________________________

(Street Address) (City) (State) (ZIP Code)

____________________________________________________________________________________

(Street Address) (City) (State) (ZIP Code)

Home Phone:(____)_____________Work Phone:(____)_____________Cell Phone:(____)___________

Email Address __________________________________________________________________ _____

Best way to contact you: cell # o home # o email o mail o Date of Birth _____/_____/______

Are You A Student? oYes oNo What grade are you currently in? __________________

Name of School: ______________________________________________________________________

Education (Highest Level Completed): __________ Licenses/Clinical Certification?_______________

Other then English, what languages do you speak? ___________________________________________

Do You Have Your Own Transportation? oYes oNo

Spouse/Partner’s Name: ________________________________________________________________

Emergency Contact: ___________________________________________ Phone:(____)_____________

Have You Done Volunteer Work At Another Nonprofit Organization? oYes oNo

If so, where? _________________________________________________________________________

What Type of Work Would You Like To Do Here? ___________________________________________

o Transportation o Safer-Sex Kit Production o Zack’s Kitchen

o Clinic Tasks o Gifts of Grace Program o Fundraising Volunteer

o Prevention o Events o Memorial Garden

o Board Member o Office Work o Maintenance Work

When Would You Be Available? Please Check Days and List Times

o Monday___________ o Tuesday__________ o Wednesday_________

o Thursday__________ o Friday____________ o Saturday___________

o Sunday___________

Tell us why you want to volunteer at Matthew 25 AIDS Services, Inc.: ____________________________

_____________________________________________________________________________________

Present or Previous Employer:

_____________________________________________________________________________________

(Employer) (Duties)

_____________________________________________________________________________________

(Employer) (Duties)

Business Phone: (_____)________________ Can we contact you at this number? o Yes o No

Please list three personal references. Include phone numbers and addresses.

_____________________________________________________________________________________

(Name) (Address) (Phone)

_____________________________________________________________________________________

(Name) (Address) (Phone)

_____________________________________________________________________________________

(Name) (Address) (Phone)

Social Security #: ________ - ______ - _________ Driver’s License #:___________________________

Have you ever been charged with a misdemeanor or felony? oYes oNo

If so what is the nature of the offense? _____________________________________________________

_____________________________________________________________________________________

I verify that all information on this application is true and that I did not withhold any information. I also give permission for Matthew 25 to run a check on my background for any criminal charges.

____________________________________________ _______/_______/_______

(Signature) (Date)