CITY OF LEBANON
VOLUNTEER APPLICATION
Please print or type. Complete entire form. If a question is not applicable, please indicate by typing
“N/A”. If addition space is needed you may attach an extra sheet.
APPLICANT DATA
1. Position Applying For and Department/Program 2. Application Date
3. Last Name Legal First Name Middle Preferred First Name
4. Are any of your work or education records listed under another name? If so, what name?
5. Birth Date (required) 6. Driver’s License Number (required) 7. Issuing State
8. Mailing Address (if different than street address)
9. Home Telephone Number Work Telephone Number Message Telephone Number
INTERESTS/SKILLS
10. Please list any special interests or professional skills.
AVAILABILITY
11. Please circle days and list hours available to volunteer: M T W Th F S
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EMPLOYMENT/VOLUNTEER HISTORY
12. Please list each job separately including unpaid and volunteer work, starting with the most recent (Job No. 1). If
additional space is needed, copy page 2 or attach additional pages; any additional information must be provided in
the same format.
Job No.
1: If currently employed, may we contact your supervisor YES NO
From: mo/yr
To: mo/yr
Employer Name
Job Title
Total time in position:
Years: Months:
Employee Address (number and street)
Supervisor Name
Average number of hours
worked per week:
City State Zip
Supervisor Phone Number
Duties:
Job No 2:
From: mo/yr
To: mo/yr
Employer Name
Job Title
Total time in position:
Years: Months:
Employee Address (number and street)
Supervisor Name
Average number of hours
worked per week:
City State Zip
Supervisor Phone Number
Duties:
DECLARATION
13. I consent to any *reference checks, and understand that such reference checks may include employment, criminal
history, and driving record information.
*Pl
ease identify any states in which you have resided over the past twenty (20) years:
/ /
Applicants Signature Date
City of Lebanon
Affirmative Action Statistical Supplement
FOR CITY OF LEBANON USE ONLY
As per City Ordinance No. 2303, CCH completed by , on .
Local DMV CCH
Approved Denied Notes: ___________________________________________________
Chief of Police: _____________________________________________________
Signature
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signature
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As an employer, the City of Lebanon is required to collect, record, and compile personnel affirmative action data. This
information is confidential and will be retained in Human Resources separate from your application for employment.
Supplying this information is voluntary; failure to provide this information will not adversely affect consideration for
employment. It is the City’s policy to consider applicants on an equal basis for all positions without regard to sex, age,
race, color, religion, national origin, marital or veteran status, sexual orientation, disability or other protected status or
activities in accordance with law.
Name (please print or type) Birth Date
Position Applying For
Sex: _____ Mal
e U.S. Citizen: Yes
_____ Female No
Check one of the following:
American Indian or Alaskan Native A person having origins in any of the original peoples of
North America and South America (including Central America), and who maintains tribal affiliation or community
attachment.
Asian 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
Philippine Islands, Thailand, and Vietnam.
Black or African American A person having origins in any of the Black racial groups of Africa.
Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic or Latino (All races) A person of Mexican, Puerto Rican, Cuban, Central or South American, or other
Spanish culture or origin, regardless of race.
If you checked Hispanic, please check one of the following Ethnic Groups:
Hispanic or Latino (White race only) A person of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, and of the White race.
Hispanic or Latino (all other races) A person of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, and of any race other than White.
Have yo
u ever been convicted of a crime? Yes No
If yes, please explain the circumstances including when, where, and the disposition of the case. (Exclude those cases
contained within expunged juvenile record and minor traffic violations.) Conviction does not necessarily disqualify you
from further consideration for employment.
Volunteer Application(R0
117
.doc
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