Name:

           
Social Security Number:

Street Address:                                                                                   State                 Zip Code:
                                

Telephone Numbers:

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

If you have any special skills, experience or training that you feel would benefit SCAN, please indicate and explain:

 Previous volunteer experience:

Why are you interested in volunteering to be a member of SCAN’s Board of Directors?

Birthdate:  Month and Day:

CURRENT AND PREVIOUS MANAGEMENT WORK EXPERIENCE

Current:

From (Month/Year):

To (Month/Year):

Duties:

Title:



Address:



Supervisor:

Firm:

EDUCATION

Name:

Years/Degree:

Field of Study:

                              PERSONAL REFERNCES 

Name:

Address:

Phone Number:

Name:

Address:

Phone Number:

Name:

Address:

Phone Number:


In case of emergency, please notify: 

Name:

Home Phone Number:

Work Phone Number:

Have you ever been substantiated for child abuse (physical, sexual or child neglect)? 

No Yes

Have you ever been convicted for child abuse (physical, sexual or child neglect)? 

No Yes

I authorize SCAN, Inc. to conduct an investigation concerning all statements contained on this application for volunteering to be a member of their Board of Directors and to interview all necessary references and former employers.