Date of Application:

Are you at least 18 years of age?

Yes    No

Other last name(s) you have used:

 Name: Last, First, Middle

Cell Phone:

 Current Street or Rural Route Address:

Work Phone:

 City:

State:

Zip:

Home Phone:

 Previous Street or Rural Route Address:

Have you ever been convicted of a felony? □ Yes □ No If yes, please describe circumstances on a

separate sheet of paper and attach.

Are you willing to do a background check? □ Yes □ No

 City:

State:

Zip:

  Email Address:

  Date available:

Days/Hours:

 What motivates you to volunteer at the Pregnancy Options Center for Warren County?

  How does your faith in Christ play a role in volunteering?

 

Applicable Employment / Volunteer History: Please list present and previous work and periods of employment. Please attach resume.

Employer/Org:

Position:

From (Mo/Yr):

To (Mo/Yr):

Contact Name:

 Street Address:

City:

State:

Zip:

Phone:

 Main Duties:

 Reason for Leaving:

 
Employer/Org:

Position:

From (Mo/Yr):

To (Mo/Yr):

Contact Name:

 Street Address:

City:

State:

Zip:

Phone:

 Main Duties:

 Reason for Leaving:

 
Employer/Org:

Position:

From (Mo/Yr):

To (Mo/Yr):

Contact Name:

 Street Address:

City:

State:

Zip:

Phone:

 Main Duties:

 Reason for Leaving:

 
Employer/Org:

Position:

From (Mo/Yr):

To (Mo/Yr):

Contact Name:

 Street Address:

City:

State:

Zip:

Phone:

 Main Duties:

 Reason for Leaving:

EDUCATION:

Name of Institution:

State

Graduated?

Degree/Certificate:

Major:

 High School:

 

Yes    No

 

   College:

 

Yes    No

 

  

 

 

Yes    No

 

  

 

 

Yes    No

 

  Professional Licensure:

 

Yes    No

 

  Certificate:

 

Yes    No

 

 

PROFESSIONAL REFERENCES: Please provide 3 references, including one from your home church.

Name:

Title/Occupation:

Company Name:

 Association to you:

Work Phone:

Alternate Phone:

 Name:

Title/Occupation:

Company Name:

 Association to you:

Work Phone:

Alternate Phone:

 Name:

Title/Occupation:

Company Name:

 Association to you:

Work Phone:

Alternate Phone:

AUTHORIZATION FOR RELEASE OF INFORMATION / PRE–EMPLOYMENT STATEMENT: Please read carefully before signing.

I understand and agree that:


  1. The information given herein is true and complete to the best of my knowledge. Any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Pregnancy Options Center of Warren County.

  • I authorize investigation of all statements contained in this volunteer application in arriving at a decision (including employment reference checking and background/credit check). I hereby authorize my current and former employers and references to furnish any information about me and about my work experience. I release my current and former employers, individual references, and entities from any and all liabilities or damages of any nature as a result of providing such information. My current and former employers and references may rely on a signed copy of this release

  • Neither this document nor any volunteer agreement or subsequent offer of employment from the Pregnancy Options Center of Warren County constitutes an employment contract unless a specific document to that effect is executed by the pregnancy Options Center and me in writing.
  • I am required to abide by all policies, procedures, rules and regulations of the Pregnancy Options Center of Warren County.

  • I understand, also, that I must be willing and able to demonstrate commitment to the Pregnancy Options Center of Warren County’s vision, mission, purpose, philosophy, core operational values, core beliefs, and commitment to care and competence in the execution of any and all tasks and responsibilities.

  • Completing this form does not indicate there is an available position and does not obligate the Pregnancy Options Center of Warren County to place me on staff as a volunteer.
  • Signature:       Date:    

    NOTE: Unsigned applications will not be considered for employment.