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>w ....V <br />-4- <br />UNSALARIED EXPERIENCE <br />Volunteer Organization Mailing Address Phone No. • <br />Position Held;Duties Performed: <br />irnmediate Supervisor: <br />Dates of Participation:Hours Per Week Skills Learned: <br />List additional information on sen^'-ate sheet if necessary. <br />CONVICTION INFORMATION <br />We declare that the existence of a criminal conviction record will not automatically disqualify you <br />from employment with us, though certain types of criminal conviction may prohibit you from working <br />in certain positions. <br />I hereby certify that all answers to the above questions are true and I agree and understand any false <br />statements contained In this application may cause rejection of this application or termination of em­ <br />ployment. I authorize that a transcript may be requested where necessary to verify any educational re­ <br />cord. <br />VIA' <br />Volunteer Organization Mailing Address Phone No. <br />Position Held:Duties Performed: <br />Immediate Supervisor: <br />Dates of Participation:Hours Per Week Skills Learned: <br />Have you ever been convicted as an adult for a criminal violation? Yes ( )oZIf yes, date and place Nature of Offense Disposition <br />If yes, date and place Nature of Offense Disposition <br />. Signature • < Date, r -^ i j <br />. i... <br />-----------------■-•i---------------------1—:—- <br />.:v *1* <br />i..