Bureau Of Land Management Volunteer Application Page 2
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212. Please specify any physical/medical limitations that may influence your volunteer work activities. Include allergies,
medications, etc.:
13a. Which months would you be available for volunteer work?
February
March
April
May
August
January
June
July
September
October
November
December
13b. How many hours per week would you be available for volunteer work'? Hours:
13c. Which days per week would you be available for volunteer work
Tuesday
Wednesday
Thursday
Friday
Saturday
Monday
Sunday
14. Specify at least three states or specific locations within a state where you would like to do volunteer work:
15. Specify your lodging requirements:
I will furnish my own lodging (such as, tent, camper, trailer, own home, relative's or friend's home)
I will require assistance in finding lodging.
16. If a volunteer assignment is not available at the locations specified in item 14, do you want your application forwarded
to another location or Federal agency seeking volunteers your background/interest?
Yes
No
17. This space is provided for more detailed responses. Please indicate the item numbers to which these responses
apply:
18. REFERENCES (include name, address, telephone number and relationship):
1.
2.
3.
4.
NOTICE TO VOLUNTEER
Volunteers are not considered to be, nor are they, federal employees for any purposes other than Federal tort claims, injury compensation, loss
or damage to personal property, and situations involving assaults, threats, and batteries while engaged in the performance of their official duties.
Volunteers are not permitted by Federal law, nor should they be assigned to perform: (1) any law enforcement work (2) any hazardous duty (3)
any work in the policyrnaking process. Volunteers may also be required to undergo background checks, provide requested information, and
authorize the disclosure of information pertaining to themselves for this purpose. Volunteer service does not qualify for Federal leave accrual
or any other benefit. However, volunteer service can be credited as work experience.
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act (PL 93-579) 5 U.S.C. 301 and 7 CFR 260 authorized acceptance of the
information requested on this form. The data will be used to contact applicants and to interview, screen, and select them for volunteer
assignments. Furnishing this data is voluntary.
Date:
19. Signature: (Sign in ink)
Form 1114-10 (January 2001) (Page 2)
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