Basic Info

Name:__________________________________ Phone: ( ____ ) ___________________    E-Mail Address: _________________________________________    

Address:_______________________________________   City________________________________________________             Zip________________

SS #:_____-_______ -______         DOB: ___/____/_______   NCDL #:______________________     Exp. Date:_____/______/___________

Auto Insurance Carrier: __________________________________   Insurance Exp. Date:_____/____/________   Date Verified:_________________

Emergency Contact Person: __________________________________________         Relationship:____________________________________

Phone: _______________

Why are you interested in volunteering as a mentor?

________________________________________________________________________________________________________

________________________________________________________________________________________________________

About You


What are your hobbies, skills, special talents, interests?

___________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________


Do you have any history of excessive use of any drugs (illegal, over the counter, prescription,
and/or alcohol)?
___________________________________________________________________________________________________________________________________________________

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Have you ever been convicted of a misdemeanor or felony other than traffic offenses?  ____________

If yes, state offense and date of conviction

___________________________________________________________________________________________________________________________________________________

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Have you ever been convicted of a traffic offense? ____________________

If yes, dates:
________________________________________________________________________

References

List three references (not relatives) who have known you for at least one year.
1. Name: ______________________________

Home Phone: ( _____ ) ______________           Work Phone: ( _____ ) _______________________

Email: _________________________________________________________________________________


2. Name: ______________________________

Home Phone: ( _____ ) ______________           Work Phone: ( _____ ) _______________________

Email: _________________________________________________________________________________

3. Name: ______________________________

Home Phone: ( _____ ) ______________           Work Phone: ( _____ ) _______________________

Email: _________________________________________________________________________________

I certify that all information on this application is true to the best of my knowledge. I give my permission to the coordinator of this program to contact the references listed above. I also give my permission for a criminal background check and driving history check to be conducted.

Signature:______________________________________________ Date:_________________________

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