Volunteer Application

Application Date*

MonthDayYear

Full Name*

First NameMiddle NameLast Name

Phone Number (Home)*

Area CodePhone Number

Phone Number (Cell)*

Area CodePhone Number

Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Have you ever been employed by Pacific Northwest University of Health Sciences?

YesNo

Are you at least 18 years old?*

YesNo

What days/hours are you available to volunteer?

Days Available

Hours Available

Have you been convicted of a crime and/or released from confinement following a conviction related to theft, fraud, violence, and/or drug manufacture or distribution? If yes, please give date, place and nature of each such conviction. Arrest or charges that have been expunged do not need to be disclosed.

Have you had any findings made against you in any civil adjudicative proceeding?

Have you ever been suspected or directly or indirectly associated with terrorist activity as defined by the USA PATRIOT Act?

Type of Volunteer:

Front Desk Reception: Are you able to sit for long periods? Are you comfortable greeting guests and providing quality customer service? Are you able to dress professionally?Other

Name

Phone Number

Area CodePhone Number

Your Association

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name

Phone Number

Area CodePhone Number

Your Association

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name

Phone Number

Area CodePhone Number

Your Association

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Company#1:

Company Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Duties

Company #2:

Company Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Duties

Company #3:

Company Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Duties

This section is optional

Race/Ethnicity (Please check one of the descriptions below corresponding to the ethnic group with which you most identify):

Hispanic or Latino: a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North AfricaBlack or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of AfricaNative Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific IslandsAsian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand, and VietnamAmerican Indian or Alaska Native (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America) who maintains tribal affiliation or community attachmentTwo or More Races (Not Hispanic or Latino): all persons who identify with more than one of the above five racesI do not wish to complete this self-identification

Under penalty of perjury, I certify that the above information is true, correct and complete. I understand that if I am chosen to volunteer, I can be discharged for any misrepresentation or omission in the above application. I also understand that if I am chosen to volunteer, it is conditioned on receipt of a satisfactory report from the Washington State Patrol. I understand that I will not be approved for volunteerism if I have ever been a suspected terrorist or associated directly or indirectly with terrorist activities, as defined by the USA PATRIOT Act.

Signature:*

My typed signature is my symbol and intent of authentication where I willingly signed, understand, and adopt this document.

We may request your fingerprints to complete the Washington State Patrol report for record or criminal convictions for offenses against persons, civil adjudications, and disciplinary board of final decisions. We will make you a copy of the report upon your request.

Date:

MonthDayYear

Pacific Northwest University of Health Sciences is a Drug Free Workplace and Equal Opportunity Employer.

Please click the Submit Form button to send it electronically or print the application and fax/scan or mail it to:

Pacific Northwest University of Health Sciences
Attn: Human Resources
111 University Parkway, Ste. 202
Yakima, WA 98901
HR@pnwu.edu
P: 509-452-5100 F: 509-452-5101

Personal Data

REFERENCES List three references who know your work or volunteerism:

VOLUNTEER HISTORY