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2. First Name
3. Middle Name
4. Last Name
6. Address
8. City
9. Zip Code
11. Phone
12. Cell Phone
13. Email Address
15. Date of Birth
16. Veteran of the U.S. Military Service?

    1. Yes
    2. No
18. Have you ever been convicted of a crime?

    1. Yes
    2. No
20. If you answered “yes,” you must provide the action, location(s), date(s) and the agency involved for each conviction.
22. Have you ever been acquitted or found not guilty of a criminal offense involving sexual conduct, murder, assault, or any other crime involving violence?

    1. Yes
    2. No
24. If you answered “yes,” you must provide the offense(s), date(s), location(s) and the law enforcement agency involved.
26. Relevant Instructor/Volunteer Skills
28. Job Experience (Please Begin With Most Recent)
30. Employer 1
31. Date Employed
    Date Employed Start Date

    —

    Date Employed End Date
33. Address
35. Job Title
37. Work Performed
39. Supervisor's Name
40. Supervisor's Phone Number
42. Employer 2
43. Date Employed
    Date Employed Start Date

    —

    Date Employed End Date
45. Address
47. Job Title
49. Work Performed
51. Supervisor's Name
52. Supervisor's Phone Number
54. References (Not Included in the Above)
56. Reference Name
58. Address
59. Phone Number
61. Reference Name
63. Address
64. Phone Number
66. Reference Name
68. Address
69. Phone Number
71. Education
73. High School Attended
74. Year Graduated
76. Colleges / Universities Attended
77. Year Graduated
79. Certificates & Skills (First Aid / Cpr, Language, Etc.)
81. Signature Agreement
    I certify that, to the best of my knowledge and belief, all statements made herein or attached hereto are true, complete, and accurate. I understand and agree that any incorrect statements or omissions of material facts herein may cause forfeiture on my part of all rights to contracting/volunteering with the City of Quincy Parks & Recreation Department. I consent to a background investigation conducted by the City of Quincy to include criminal history, driving record, current and past employers and personnel files, as well as all information described in RCW 43.43.830-.839 (which provisions are incorporated into this application), and authorize the City of Quincy to investigate any of the information provided by me. I waive any right of privacy I may have in such information for the limited purpose of the City considering it for determining my suitability as a Volunteer and further waive any right to inquire as to the contents of, or obtain copies of, the material secured as a result of such investigation. I also authorize the previous employers, persons, and references named or any other person or entity named to give any and all information regarding employment, scholastic records, together with all other job related information that may or may not be on record. I release the City of Quincy and their officers and employees, and all other individuals or entities who provide information to the City of Quincy from all liability resulting from the release and use of such information.
83. Signature

    1. I Certify
84. Date
    Date
Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field