Become a Volunteer Correspondent

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Correspondent Application

Name

First

Last

Maiden Name

Name(s) you’ve gone by in past

Drivers License No.

Address

City

State/Province

Zip/Postal

Date of Birth

Phone

home

Phone Work

work

Phone Cell

cell

Have you ever been convicted of a crime?

Yes

If so, please explain

Person with whom you would like to be matched

full name

Match's Phone

Match's Address

City

State/Province

Zip/Postal

Case Manager

Case Manager Full Name

Case Manager Email

Case Manager Phone

Guardian

Guardian Full Name

Guardian Email

Guardian Phone

Related Experience

Volunteer and related experience.

other than employment

Type of person who interests you most

age, interests, abilities, etc.

Your special skills and interests

hobbies, sports, sign language, etc. Any activity you could share with the person

References

Two personal references (other than employers or family members. A telephone number must be listed.)

Reference 1 Full Name

Reference 1 Address

City

State/Province

Zip/Postal

Reference 1 Phone

home

Reference 1 Phone Work

work

Reference 1 Phone Cell

cell

Reference 2 Full Name

Reference 2 Address

City

State/Province

Zip/Postal

Reference 2 Phone

home

Reference 2 Phone Work

work

Reference 2 Phone Cell

cell

Repeater

If you have paid work experience, please list your employers for the past 5 years beginning with the most recent. A telephone number must be listed. Work references may be contacted.

Position

Supervisor

Company

Address

Dates

start

Date

end

Add Remove

Signature

I authorize the Consumer Advisory Board to verify all information contained in this application, to contact my personal and professional references, and to contact the State Bureau of Identification about me. I understand that I may be required to attend trainings for volunteer correspondents and I agree to attend.

Signature

Clear

Date

If you are human, leave this field blank.