First Name*:

Last Name*:

Birthdate*:

Address*:

City*:

State*:

Zip Code*:

Previous Address:
If you've lived at your current address for less than one year, please list your previous address below.

Previous Address:

Previous City:

Previous State:

Previous Zip Code:

Employer Information:
Please provide the following information about your occupation and employer.

Employer's Address*:

Employer's City*:

Employer's State*:

Employer's Zip Code*:

Contact Information:
Please provide information about where we may contact you below.

Fax Number*:

Volunteer Information:
Please check the activities below, which you are the most interested in.

Clerical Support

Public Awareness Committee Member

CASA (Court Appointed Special Advocate)

Availability:
Please list your possible availability (check all that apply):

Daytime

Previous Experiences:
List previous experiences (volunteer, paid or educational) that would assist you in your role at the CAN Council.

Why do you wish to volunteer with the CAN Council?

How did you learn about volunteer opportunities available through the CAN Council?

Is it necessary for you to limit your physical activity in any way? If yes, please explain.

In Case of Emergency:
Please provide the contact information of the individual who should be notified in case of an emergency.

Address*:

City*:

State*:

Zip Code*:

Education:
Please list your educational background below.

High School*:

College Name:

Last Year Completed:

Degree/Field of Study:

Previous Employment:
Please list your previous three employers and positions below:

Diversity Information (Optional):
The following information is used only to determine diversity of council volunteers. Completion is optional.

African American

By submitting this form, I certify that the information given in this application is correct to the best of my knowledge, and permission is hereby given for any investigation that may be necessary. I understand that misleading or untruthful information on this application may result in my dismissal.