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CITY OF FARMINGTON VOLUNTEER CANDIDATE INFORMATION Thank you for your interest in seeking to become a volunteer with the City of Farmington. Volunteer Candidate Information is used to determine suitable placement. Please type or complete this form in ink as neatly and clearly as possible. Answer all questions to the best of your knowledge. Position: Full Name: DATE: Mailing Address: Number & Street City State Zip Code Street Address: If different from above Daytime Phone: Evening Phone: E-mail: Birthday(mo/day): Cell Phone: May we contact you via text message: ___Yes ___No I give permission for my name and address / e-mail to be put on a general mailing list to receive any mailings from other departments within the City of Farmington Address: ___Yes ___No E-mail: ___Yes ___No Please list other areas of interest: (See List of Volunteer Opportunities) How often are you available to volunteer? Once a week Once a month Daily Other please specify: q I am under the age of 18 (You must provide the parental consent form, on page 4 of application) q I am 18 or older What times of day are you available? MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY AM PM Are you interested in volunteering in more than one location? ___Yes ___No For special events? ___Yes ___No Are you currently a City of Farmington employee? ___Yes ___No Have you ever worked for the City of Farmington? ___Yes ___No Employment Dates (mo/yr) Are you volunteering to complete a requirement of hours? ___Yes___No If yes, list name of organization and number of hours required City of Farmington PLEASE RETURN VOLUNTEER CANDIDATE INFORMATION TO: CITY OF FARMINGTON HUMAN RESOURCES OFFICE 850 MUNICIPAL DR FARMINGTON NM 87401 ² (505) 599-1132 or e-mail to [EMAIL REDACTED] ---PAGE BREAK--- CITY OF FARMINGTON VOLUNTEER CANDIDATE INFORMATION Do you have a High School Diploma or a G.E.D.? ___Yes ___No If No, indicate highest grade completed.______ Employment History Current Employment Company: Address: Supervisor: Phone: Start Date: End Date: Other Info: Previous Employment History Previous Employment Company: Address: Supervisor: Phone: Start Date: End Date: Other Info: Previous Employment Company: Address: Supervisor: Phone: Start Date: End Date: Other Info: Volunteer Activities Company: Address: Supervisor: Phone: Start Date: End Date: Other Info: Education from an Accredited College/University: College Major Type of Degree Degree Completed? Credit Hours Yes No Language Proficiency (Other than English): Language Speak Read Write Yes No Yes No Yes No Language Proficiency (Other than English): Language Speak Read Write Yes No Yes No Yes No List two persons to contact in case of emergency. The second person will be called if the first person can not be reached. Name: Relationship: Daytime Phone: Evening Phone: Name: Relationship: Daytime Phone: Evening Phone: For safety considerations, do you have any medical or physical conditions that would involve special placement or accommodation? ___Yes ___No If Yes, please explain: ---PAGE BREAK--- CITY OF FARMINGTON VOLUNTEER CANDIDATE INFORMATION The City of Farmington considers candidates for volunteer service based on qualifications for specific volunteer jobs within the City and at the various departments or divisions without regard to race, color, religion, sex, national origin, age, disability, or any other legally protected status. LIABILITY WAIVER/ACKNOWLEDGEMENTS I waive any claims against the City of Farmington, its agents, officers, employees and volunteers from any and all liability and release and hold harmless for death, personal injury, and destruction of property, loss, expense or claim for injury or damages not caused by the intentional acts of City of Farmington employees or the gross negligence of said employees arising from my participation as a volunteer. I realize that each department/division and event holds unique risks depending upon its nature. For example, a volunteer who works in the animal shelter will be exposed to risks of working with animals, e.g. dog behavior and risks in exercising animals, and a volunteer who works at the golf course may be exposed to risks of in-air golf balls. These risks are inherent, and they vary according to the nature of each division or event and the details of the volunteer position, and I accept these risks. I understand I would not be compensated for any of my services and that my placement as a volunteer would not result in employment with the City of Farmington. I understand that volunteer placement is conditioned upon favorable background information as determined by the City of Farmington . I understand that the City of Farmington is not obligated to provide me with a volunteer placement, and I am not obligated to accept the volunteer position offered. I understand that the City of Farmington reserves the right to terminate my volunteer status at any time. As a volunteer I understand I may be photographed for educational, archival, and public relations purposes. Initials:________ Signature of Applicant Date of signature The City of Farmington complies with the Civil Rights Act of 1964, the Age Discrimination Act of 1967, the Rehabilitation Act of 1973, and the American Disabilities Act of 1990. ---PAGE BREAK--- CITY OF FARMINGTON VOLUNTEER CANDIDATE INFORMATION VOLUNTEER CANDIDATE RELEASE FORM The City of Farmington may conduct an extensive background investigation of criminal history. A criminal conviction does not constitute an automatic bar to placement. Each case is considered individually and based on job requirements. However, failure to answer truthfully will result in disqualification for placement with the City of Farmington. “Crime” as used in this section means any and all felonies, misdemeanors, and serious driving offenses. “Crime” does not include minor civil traffic offenses. If you are unsure how to answer this question, please ask for assistance. “Convicted” means that you have been found guilty by a court or jury, pleaded guilty or no contest to a crime and/or have been sentenced for a crime, whether incarcerated, placed on probation, fined, or received suspended sentence. Have you ever been convicted of a crime, regardless of whether the conviction was later set aside or expunged, in any domestic, foreign or military court? ___Yes ___No Are you pending charges, trial or other court proceedings for any crime, in any jurisdiction, at this time? ___Yes ___No If you answered yes to either or both questions, please give details including the offense(s) for which you were convicted or are currently pending charges, date of conviction, and jurisdiction (court, city, county and state), on a separate sheet of paper. If an offense has been set aside or expunged, please give date of action. CONDITIONS I fully understand that the City of Farmington, to protect its citizens, will conduct a background check of my name through law enforcement agencies and license bureaus and any or all of the following may be required before placement in any sensitive volunteer position: Background Investigation including police and court records Fingerprinting Substance Abuse Testing Motor Vehicle Check Authorization for the Release of Information and Records: I am seeking to become a volunteer with the City of Farmington and I hereby direct and authorize the City of Farmington conduct a thorough background check through any agencies the City of Farmington deems necessary. I waive and release any and all manner of actions, causes of action, and demands of every kind, nature and description, arising from any release of criminal records and request there from, whatsoever against the State of New Mexico, City of Farmington, in both law and equity, which I may have now or in the future. Age: Date of Birth: Social Security Number: Driver’s License Number and State of Issue: Address: Candidate Printed Name: Candidate Signature: As a parent/guardian of above applicant, I consent to allow to volunteer with the City of Farmington under the terms listed. Additionally, I understand that transportation is not the responsibility of the City of Farmington, and that once a volunteer leaves the City property; they are no longer under the responsibility of the City of Farmington. I further understand the conditions outlined above regarding a potential background check being conducted. Parent/Guardian Signature: (if candidate is a minor) Date: If Parent/Guardian Signature required: Sign and date in the presence of a Notary Public. Signature indicates understanding and acceptance of the above conditions. State of New Mexico, City of Farmington, County of San Juan Subscribed and sworn to before me this day Date Commission Expires Notary Public The City of Farmington complies with the Civil Rights Act of 1964, the Age Discrimination Act of 1967, the Rehabilitation Act of 1973, and the American Disabilities Act of 1990.