also see in km folders...other style master copy
New Hampshire Fish and Game Department
Fish and Wildlife Stewards Application
Please type or print neatly
Name: (Last) (Maiden/Alias) (First) (Middle)
Mailing Address: Home Phone ( )
______Work Phone ( )
(City)(State)(Zip)
Cell Phone: ( )
Physical Address:
(if different from mailing address – for UPS deliveries) Email: ______
(City)(State)(Zip)
Why do you want to become a Fish and Wildlife Steward?
______
Are you willing/able to make a commitment to attend a minimum of six sessions of required class time and give back at least 40 volunteer hours in the two years following completion of the training?
_____ Yes_____ NoIf no, please explain ______
Once the training is complete, when are you able to volunteer?
_____ weekdays_____ weekends_____ evenings
I am willing to travel miles to a speaking or other volunteer opportunity.
Have you ever had any Fish and Game violations? Please explain.
References: Please provide the following information for 3 references outside your family:
Name: ______Day phone: ______Occupation: ______
Name: ______Day phone: ______Occupation: ______
Name: ______Day phone: ______Occupation: ______
Background Information: (Attach additional sheet if necessary)
Relevant educational courses (biology, wildlife, fisheries, communications, etc.):
Special skills, training or experience:
Currently volunteering with:
Clubs and associations:
Hobbies, interests:
I fully understand that I will be investigated prior to my acceptance to the Fish and Wildlife Stewards Program and I hereby consent to a Bureau of Criminal Records review.
Signature: Date:
(Each application must bear a current date and original signature.)
Please send completed applications to:
Mary Goodyear
Fish and Wildlife Stewards Program
New Hampshire Fish & Game Dept.
11 Hazen Drive
Concord, NH 03301
603/271-6649
Questions:
Voluntary Racial / Ethnic SurveyYour response to this question will help us track important civil rights information and aid in our recruitment efforts. It is STRICTLY VOLUNTARY and will be kept CONFIDENTIAL
Please identify yourself in terms of the racial/ethnic groups below:
□ Hispanic□ African American
□ Asian □Caucasian
□ Native American (American Indian and Alaskan Native) / This program receives Federal financial assistance from the US Fish and Wildlife Service. Under Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, Title IX of the Education Amendments of 1972, the US Department of the Interior and its bureaus prohibit discrimination on the bases of race, color, national origin, age, disability, age or sex (in educational programs). If you believe that you have been discriminated against in any program, activity, or facility, or if you desire additional information please write to:
The US Fish and Wildlife Service
Office for Diversity and Civil Rights Programs - External Affairs
4040 N. Fairfax Drive, Suite 130
Arlington, VA 22203
Updated 1/20/11
New Hampshire Fish and Game Department
11 Hazen Drive
Concord NH 03301
FISH & WILDLIFE STEWARDS & WONDERS OF WILDLIFE DOCENT PROGRAM
CRIMINAL RECORD RELEASE AUTHORIZATION FORM
PLEASE TYPE OR PRINT CLEARLY, ALL INFORMATION MUST BE COMPLETED
NAME
LASTMAIDEN/ALIASFIRSTMI
ADDRESS
STREETCITYSTATE ZIP CODE
DATE OF BIRTH HAIR COLOR EYE COLOR SEX
DRIVER LICENSE NUMBER STATE
SOCIAL SECURITY NUMBER
(Optional)
I fully understand that I will be investigated prior to my appointment as a steward or docent and I hereby consent to a Bureau of Criminal Records review. Additionally, I also fully understand and consent to recurring investigations and Bureau of Criminal Records reviews that may be conducted while I am affiliated with either of the two programs.
My signature below certifies that I am the individual listed above and the information provided is true
YOUR SIGNATURE DATE Signed under penalty of unsworn falsification pursuant to RSA 641:3