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4- <br />UNSALARIED EXPERIENCE <br />Volunteer Organization 01� <br />Mailing Address <br />Phone No. <br />Position Held: <br />Duties Performed: <br />Immediate Supervisor: <br />Dates of Participation: <br />Hours Per Week <br />Skills Lamed: <br />Volunteer Organization <br />Mailing Address <br />Phone No. <br />Position Held: <br />Duties Performed: <br />Immediate Supervisor: <br />Dates of Participation: <br />Hours Per Week <br />Skills Learned: <br />List additional information on separate 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 />Have you ever been convicted as an adult for a criminal violation? Yes ( ) No M <br />If yes, date and place N/A Nature of Offense Disposition <br />If yes, date and place /V/lq Nature of Offense Disposition <br />J <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 neceseary to verify any educational re- <br />cord. <br />/o1141if8 <br />Signatur Date <br />