Volunteer Application Step 1 of 3 33% Contact InformationName* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work Phone*Email* AvailabilityDuring which hours are you available for volunteer assignments?* Weekday mornings Weekday afternoons Weekday evenings Weekend mornings Weekend afternoons Weekend evenings InterestsTell us in which areas you are interested in volunteering* Administration Events Field work Fundraising Deliveries Phone bank Newsletter production Volunteer coordination Special Skills or QualificationsSummarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities, including hobbies or sports.*Previous Volunteer ExperienceSummarize your previous volunteer experience.* Agreement and SignatureTerms & Conditions* By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, missions, or other misrepresentations made by me on this application may result in my immediate dismissal.Signature*Name* First Date* Date Format: MM slash DD slash YYYY Our Policy* It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.Thank you for completing this application form and for your interest in volunteering with us. CONFIDENTIALBackground Check AuthorizationPrint Name* First Middle Last Former Name(s) and Dates Used:Current Address Since:* Street Address City State / Province / Region ZIP / Postal Code Date* Date Format: MM slash DD slash YYYY Previous Address From: Street Address City State / Province / Region ZIP / Postal Code Date Date Format: MM slash DD slash YYYY Previous Address From: Street Address City State / Province / Region ZIP / Postal Code Date Date Format: MM slash DD slash YYYY Social Security Number*Date of Birth* Date Format: MM slash DD slash YYYY Telephone Number:*Drivers License Number/State:The information contained in this application is correct to the best of my knowledge. I hereby authorize Bloom Upstate and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to Bloom Upstate or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. Bloom Upstate and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.Signature*Date* Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.