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Subscribing
Life
Youth
NHQ
Mr.
Mrs.
Ms.
D.O.B ________________________
Dr.
Other
3. Home Address_____________________________________________________________________
4. Contact Numbers___________________________________________________________________
5. E-mail Address_______________________________________________
B. EMERGENCY CONTACT PERSONS
In case of emergency notify:
1. First Contact Person: Name_______________________________________________________________
Relationship_________________________________________
2. Address_________________________________________________________________________________
3. Contact Numbers__________________________________________________________________
4. Second Contact Person: Name ____________________________________________________
5. Relationship________________
6. Address__________________________________________________________________________
7. Contact Numbers ________________________________________________________________
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C. WORK EXPERIENCE
1. Profession or Occupation__________________________________________________________
2. Primary place of Employment _____________________________________________________
3. Work Address
4. Work Telephone#__________________________________________________________________
5. May we contact you at work?
Yes
No
D. LICENSES
1. Drivers (Type)____________________________________Expiration Date_________
2. Professional_____________________________________ Expiration Date_________
E. EDUCATION
21. Highest Educational Achievement (check one)
M.A.
Doctorate
Elementary School
High School
B.A.
Other
F. VOLUNTEER EXPERIENCE
List any current or past volunteer service involvement
1. Organization(s) served __________________________________________________________
___________________________________________________________________________________
2. Service(s) rendered _____________________________________________________________
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G. PERSONAL REFERENCES
Indicate two persons, other than members of your family, who can serve as your references.
These persons will be contacted.
1. Name ________________________________________ 2. Address ____________________________
3.Contact #s ____________________________________
4. Name ___________________________________
5. Address _____________________________
6. Contact #s ______________________________
H. SKILLS/INTERESTS
List any specialist skills you have:
1.
Public Relations
Accounting
Marketing/Communications
Fundraising
Medical
Nursing
Clerical
No
French
Sign
Other _________________________
Care Section
Fundraising Committee
Other
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Title
Date
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