Fillable Form Dc5-601a - 2008 Volunteer Application Form printable pdf download

Form Dc5-601a - 2008 Volunteer Application Form

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FLORIDA DEPARTMENT OF CORRECTIONS

OLUNTEER

PPLICATION

Personal Information

Name:

L a s t

F i r s t

M i d d l e

M a i d e n

Address:

C i t y

S t a t e

Z I P C o d e

T e l e p h o n e # 1

T e l e p h o n e # 2

E - M a i l A d d r e s s

Volunteer Group Name:

Narcotics Anonymous

Security Clearance Information

Social Security #:

Date of Birth:

Race/Ethnic Origin:

Gender:

Male

Female

Drivers License #:

DL State:

1. Have you ever been arrested on a misdemeanor or felony charge?

Yes

If yes, explain. (Use additional paper if necessary)

2. Have you ever been convicted on a misdemeanor or felony charge?

Yes

If yes, explain. (Use additional paper if necessary)

3. Do you have a relationship (for example parent, spouse, friend, etc) or are you currently on the

visitation list of anyone incarcerated?

Yes

If yes, give the inmate’s name, DC#, and your relationship to the inmate.

Name:

DC#:

Relationship:

4. Have you ever worked for the Florida Department of Corrections?

Yes

If yes, please indicate where and when you were employed.

5. Do you have any relatives working for the Department of Corrections?

Yes

If yes, provide: Name:

Relationship:

Work Location:

In case of emergency notify:

Name

(area code + number)

•

Qualified applicants are considered without discrimination based upon race, color, national origin,

age religious preference, or handicap.

•

Intentionally falsifying or omitting information may result in disapproval of your volunteer

application.

I CONFIRM THAT ALL INFORMATION IS ACCURATE AND COMPLETE.

Signature

Printed Name

Date

D C 5 - 6 0 1 A ( R e v i s e d 2 / 0 8 )

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F C I C / N C I C s e c u r i t y r e p o r t s o t h a t y o u c a n b e a p p r o v e d a s a v o l u n t e e r . T h e D e p a r t m e n t w i l l n o t u s e t h e s o c i a l

s e c u r i t y n u m b e r c o l l e c t e d f o r a n y p u r p o se o t h e r t h a n t h e p u r p o s e p r o v i d e d a b o v e .