Harbor Shine - - Mosaic Resale Store - - Café Mosaic - - Jobs for Life - - Harbor Market
510 W. Main St. P.O. Box 1146 Benton Harbor, MI 49023 (269) 925-9925 www.occda.com
VOLUNTEER APPLICATION
Name: / Email: ______Address: / Telephone:
City: ______
Are you at least 18 years of age? / State: ______Zip: ______
☐ Yes
☐ No
I am completing this application as part of a mandated community service program:
Hours Needed: ______ / ☐ Yes If yes, please list name & phone of your PO:
☐ No
______
I am completing this for high school or college volunteer services:
Please list the hours you need to meet the requirements of your PO/school/college:
Total Hours Needed: ______
Have you ever been convicted of a felony? / ☐ Yes
☐ No
☐ Yes
☐ No / If yes, please list name of school/college:
Days available:
If yes, explain when, where & nature of offense: / ______
☐ Monday ☐ Tuesday ☐ Wednesday
☐ Thursday ☐ Friday ☐ Saturday
Are there any felony charges pending against you now? / ☐ Yes
☐ No / If yes, please explain:
Have you ever been convicted of child abuse or sexual abuse or ☐ Yes
been involved in any activities related to molesting or abusing ☐ No
children/youth?
If yes, please explain: ______
Have you ever been convicted a sexually based offence or have ☐ Yes
been involved in any activities criminal sexual conduct of any kind? ☐ No
If yes, please explain: ______
References (Please do not list family or anyone living with you)
Name & Occupation / Address / Phone Number
Military Service (Period of Service)
From/To:
Military Service (Continued) / Branch / Rank
Duties:
Education
Name of School / City / Course of Study / Did you graduate?
High School
College/Post-Graduate
Business/Trade
Please indicate other training, qualifications, and skills (i.e. proficiencies, language, internships, etc.)
Applicant Certification & Agreement (READ CAREFULLY Before Signing)
I hereby certify that all statements on this employment application are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed or if employed may result in my dismissal.
I authorize the references listed on this application and any prior employer, educational institution or any other persons or organizations to give the Overflow Christian Community Development Association (know hereafter as “OCCDA”) and its program and staff any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liabilities for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organizations.
In accordance with ADA requirements, if I require an accommodation to perform the job, I must notify the OCCDA Administration of that need within 180 days after I knew or reasonably should have known that any accommodation was needed. Failure to do so will bar me from alleging that the OCCDA has not accommodated me as required law.
I hereby authorize the OCCDA to secure a criminal conviction history from the appropriate law enforcement agency should the OCCDA determine it to be necessary to do so.
Applicant’s Signature / DateUpdated 4/28/15