Job Title: May we contact this employer? Yes No Description of Duties: Reason for leaving: (Attach additional sheets if necessary.) EDUCATIONAL HISTORY High School Name and Location Subjects Studied Degree and Graduation Date or # of years completed Besides MSU Ares of Major and Minor Degree and Graduation Date or # of College/University/Technical/Vocational years completed School Name and Location VOLUNTEER EXPERIENCE Agency/Organization and Address: Telephone: ( ) Name of Supervisor: Dates Volunteered May we contact this Reason for leaving: From To agency: Yes No Job Title and Duties: Telephone: Agency/Organization and Address: ( ) Name of Supervisor: Dates Volunteered May we contact this Reason for leaving: From To agency: Yes No Job Title and Duties: (Attach additional sheets if necessary.) BACKGROUND Yes No If yes, state and license #: ________________________ Do you have a valid driver’s license? Available car? Yes No If yes, name of insurance company: _________________________________ Do you have any physical or mental conditions(s) which would limit your ability to participate in activities with Blue Earth County Community Corrections: Yes No If yes, please explain (limitation(s), activity restrictions, etc.) A physical or mental condition(s) does not disqualify a volunteer. This data is required to determine how to accommodate any special needs. Have you ever been convicted of a criminal offense (including petty misdemeanors) or major traffic offense (misdemeanor or greater)? Yes No (Report all convictions past and present. (Convictions may not automatically disqualify you.) If yes, what was your offense: Date convicted: ___________________ End date of probation/parole or court jurisdiction: _________________ Are you now or have you ever been placed on probation or participated in a diversion program? Yes No If yes, please explain:
Job Title: May we contact this employer? Yes No Description of Duties: Reason for leaving: (Attach additional sheets if necessary.) EDUCATIONAL HISTORY High School Name and Location Subjects Studied Degree and Graduation Date or # of years completed Besides MSU College/University/Technical/Vocational School Name and Location Ares of Major and Minor Degree and Graduation Date or # of years completed VOLUNTEER EXPERIENCE Agency/Organization and Address: Telephone: ( ) Name of Supervisor: Dates Volunteered From To May we contact this agency: Yes No Reason for leaving: Job Title and Duties: Agency/Organization and Address: Telephone: ( ) Name of Supervisor: Dates Volunteered From To May we contact this agency: Yes No Reason for leaving: Job Title and Duties: (Attach additional sheets if necessary.) BACKGROUND Do you have a valid driver’s license? Yes No If yes, state and license #: ________________________ Available car? Yes No If yes, name of insurance company: _________________________________ Do you have any physical or mental conditions(s) which would limit your ability to participate in activities with Blue Earth County Community Corrections: Yes No If yes, please explain (limitation(s), activity restrictions, etc.) A physical or mental condition(s) does not disqualify a volunteer. This data is required to determine how to accommodate any special needs. Have you ever been convicted of a criminal offense (including petty misdemeanors) or major traffic offense (misdemeanor or greater)? Yes No (Report all convictions past and present. (Convictions may not automatically disqualify you.) If yes, what was your offense: Date convicted: ___________________ End date of probation/parole or court jurisdiction: _________________ Are you now or have you ever been placed on probation or participated in a diversion program? Yes No If yes, please explain: