This information is requested to help us better match people with similar backgrounds, experiences, or interests (available only to our staff).

Personal Information

 *

Personal Information

Name

Address

Phoneext.

Email

Profession/Work Experience

Employment Status

Employment Status

Employed Full Time

Employed Part Time

Seeking Employment

Retired

Employer Information

Employer Information

Current Employer (if any)

Employer Address

Employer Phoneext.

Emergency Contact Information

Emergency Contact Information

Contact Name

Contact Phone ext.

 Have you ever been convicted of a crime or denied bond?

Have you ever been convicted of a crime or denied bond?

Yes

No

Please describe your volunteer experience; include any service or charitable organizations whose activities may relate to this job.

Please describe your volunteer experience; include any service or charitable organizations whose activities may relate to this job.

Organization

Date you volunteered

Responsibilities

How did you hear of the MMP Program?

How did you hear of the MMP Program?

What interests you about being a money management volunteer?

What interests you about being a money management volunteer?

In addition to or instead of becoming a volunteer representative payee, would you be willing to provide help in one or more areas listed below?

In addition to or instead of becoming a volunteer representative payee, would you be willing to provide help in one or more areas listed below?

Provide Temporary Help to a Volunteer on Leave or Vacation

Assist with Volunteer Recruitment in your Area

Provide General Office Assistance (Office Aide Postition)

Education and Interests

Highest Level of Education Attained

Highest Level of Education Attained

High School

Advanced Degree

College/Other Post High School Education

Interests, Hobbies or Activities

Interests, Hobbies or Activities

Do you have any Client Preferences (check any that apply)

Do you have any Client Preferences (check any that apply)

Male

Female

Elderly

Individuals in Group Care

Individual with Drug or Alcohol Problem

Homeless

Handicapped: Mentally Physically Homebound

Do you speak any languages other than English?

Do you speak any languages other than English?

Yes

No

If Yes, which languages do you speak?

Form of Transportation

Form of Transportation

Rely on Others

Public Transportation

I drive

If you have your own car:

Policy Number

References

Please list the names, addresses, and telephone numbers of three references NOT related to you. One has to be a professional contact (teacher, minister, employer, etc.)

References Please list the names, addresses, and telephone numbers of three references NOT related to you. One has to be a professional contact (teacher, minister, employer, etc.)

Name

Address

Phoneext.

Name

Address

Phoneext.

Name

Address

Phoneext.

Volunteers are asked to make a renewable one year commitment to this job. Except for unexpected circumstances, are you willing and able to commit to the full one year term of this program?

Volunteers are asked to make a renewable one year commitment to this job. Except for unexpected circumstances, are you willing and able to commit to the full one year term of this program?

Yes

Inital (as signature)

Commnets or aditional information you wish to add

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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