1. Name_______________________________________________________________

                                        first                         middle                                 last
 

2. Address: (temporary)___________________________________________________

_____________________________________________________________________

Address: (permanent) __________________________________________________

___________________________________________________________________
 

3. Telephone/s: _______________________________________________________

                                                temporary                                         permanent
 

4. Name and Phone Number of an Emergency Contact Person:

____________________________________________________________________
 

5. Social Security Number ________________________________
 

6. Date and Place of Birth ________________________________
 

7. Are you a U.S. citizen?  ( Yes/ No ) If no, type of visa or green card___________________

_________________________________________________________________________
 

8. Religious Denomination _____________________________
 

9. Status: Single ( ) Married ( ) Widowed ( ) Separated ( ) Divorced ( )
Religious ( )

Type of Work:                                               Employer                                          Dates: from-to

____________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
 

10. Educational Background - Indicate School and dates of all degrees

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________
 

Military Service: Branch___________ Year __________ Discharge ____________
 
 

11. Please list the scope and dates of all your volunteer experience:

___________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
 

12. List all other talents or experiences your bring to volunteer service:

______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________
 

13. Do you have a driver's license?____________________________

State and license #______________________________________

Are there any violations/convictions?

Please explain:__________________________________________

______________________________________________________

Please enclose a photocopy of the license
 

14. List your favorite leisure activities:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________
 

15. Do you speak any other languages besides English? __________________
 

16. Do you have any health problem? Please indicate: ___________________

____________________________________________________________

____________________________________________________________
 

17. Are you taking medication? If yes, what kind and why

____________________________________________________________

____________________________________________________________
 

18. Indicate the pattern of your use daily, weekly, and monthly of:

Alcohol ________________________ Tobacco______________________

Any other drugs_______________________________________________
 
 

19. Have you ever been convicted of a crime? ___________________________

Describe _____________________________________________________

_____________________________________________________
 
 

20. Will your medical insurance continue during your service? _________________

List Company and Policy #__________________________________________
 
 

21. When and for how long will you be available for service?

_________________________________________________________________
 

22. Geographical preference: _____________________________________________

__________________________________________________________________
 

23. Please list the work you feel best suited for based on your educational background or personal

prefernce:

______________________________________________________________
 
 
 
 

PLEASE INCLUDE A PICTURE OF YOURSELF AND A COPY OF YOUR DRIVER'S LICENSE BELOW.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

__________________________________________ ________________________

SIGNATURE DATE
 

(Your signature will also release your photo for publication in our Provincial newsletter if you become an LSAV).
 
 

*Misstatements of facts may be reason for disqualification from the LSAV.