City of Lewisburg Animal Control Volunteer Application

Name Current Address. State ____ Social Security No.

City. ZiP -

Date

Phone Email

EDUCATIONAL BACKGROUND High School Attended______

Graduated No

Yes

College or Technical Training: School____________ School Other Education or Training. Date Attended. Date Attended Degree . Degree .

EMPLOYMENT HISTORY Current or Most Recent Employer Address City. To

State

Dates Employed: From. Your Supervisor's Name Position and Primary Duties: Phone

May we contact? _

Other organizations where you have worked and/or volunteered in the past ten years: Organization_______________________ Address Phone Position Duties and Dates Supervisor Supervisor Dates: From ___ City
To_ State

Organization ___ Position and Duties

Organization_________________Dates: From __________ To____

Address________________________City _______________ State ______

Phone__________________Supervisor_________________________________ Position and Duties

Have you ever been terminated or asked to resign by any employer or organization as an employee or volunteer? No_______ Yes ______

If yes, please explain: .______________________________________________________

Have you ever pleaded guilty, or been arrested for or convicted of a crime?

No _______ Yes ______

If yes, please explain (include dates and locations): _^____________________________________

SPECIAL SKILLS AND ABILITIES Please identify any special skills, training and abilities you feel may be useful as a City of Lewisburg Animal Control Volunteer: _____.____________________________..__..__.______...._-.______

AVAILABILITY AND TIME COMMITMENT How much time are you willing to provide the City of Lewisburg Animal Control? How many hours per week ___________ Per Month___________ .. Do you have a current TN driver's license? No _____ Yes ______ DL Number ___________________ Please state briefly why you would like to be a part of the City of Lewisburg Animal Control:

ACTIVITIES AND INTERESTS The following are activities/projects City of Lewisburg Animal Control volunteers frequently perform. Please indicate those that you feel you could perform and/or are interested in learning: D Computer/Data Entry D Internet research D Helping with kennel facility cleaning D Assisting with adoption of animals D Photographing of animals for advertising/posting for adoption D Answering telephones

REFERENCES Please provide the names, addresses and phone numbers of three non-relative references of people who know you well, and that you give us permission to contact: Name ______________________ City _______________ Phone _____________ Name _______________________ City ______________ Phone _____________ Name ______________________ City _______________ Phone _____________ Name _______________________ City _______________ Phone _____________ Person to contact in the event of an emergency: Name ___________________________ Phone __________________ I also give the City of Lewisburg permission to conduct an investigation of my background to include criminal, employment, volunteer, references, and other areas as deemed necessary by the City of Lewisburg. I certify that all information contained in this application is true and complete to the best of my knowledge and belief. I further understand that acceptance into the City of Lewisburg Animal Control volunteers is contingent upon a successful background investigation. Signature _________________________ Date ______________ BACKGROUND INVESTIGATION As an applicant for a volunteer position with the City of Lewisburg Animal Control, you are being asked to provide information about yourself which will be used to evaluate your suitability for this type of position. You are not legally required to provide the requested information. However, if you do not, the City of Lewisburg will be unable to conduct the required background inquires and will not be able to process your application and the City of Lewisburg will not be able to consider you for a volunteer position. YOUR FULL NAME ___________________________________________________^_______ First Middle Last OTHER NAMES YOU HAVE BEEN KNOWN TO USE _____._.__._.______________________________ ADDRESS YOU HAVE USED DURING THE PAST 10 YEARS: AddressCityState AddressCityState AddressCityState AddressCityState AddressCityState DATE OF BIRTH: ____________ I hereby authorize the City of Lewisburg to use this information to determine my suitability as a City of Lewisburg Animal Control volunteer. Signature Date

AUTHORIZATION FOR RELEASE OF INFORMATION

, _______________________, DO HEREBY * i -^,~~~~'~"""""-~~ AUTHORIZE any and all persons, employers, partnerships, corporations and all civilian and government entities, military agencies, law enforcement agencies, private, city, county, state and federal entities to release, furnish and exchange any and all available information relating to me for the purpose of determining my suitability as a volunteer with the City of Lewisburg Animal Control. This includes, but is not limited to, all information related to my employment, performance, disciplinary history, character, integrity, reputation, conduct, behavior and fitness for duty. This authorizes release to the City of Lewisburg or the Lewisburg Police Department. This release is in addition to and not intended to curtail or diminish the authorization and immunity provided by statute. I DO HEREBY RELEASE from any and all liability, all persons or entities disclosing information pursuant to this release. Signature of Applicant Date

CONFIDENTIALITY AGREEMENT I, _________________________ recognize that, if I am accepted into the City of Lewisburg Animal Control Volunteer Program, I will, at times, be in a position to read or come into contact with confidential, private and sensitive information in the course of my volunteer duties. I understand that this information cannot be copied, removed from the City of Lewisburg Animal Control, or shared with anyone other than the City of Lewisburg employees. I understand that a violation of this confidentiality agreement will mean termination of my City of Lewisburg Animal Control Volunteer status. Signature Date