Volunteer Application Form

City of Jacksonville

Disabled Services Division

Volunteer Application

Application for membership as a Auxiliary Officer

Last Name, First Name:	Street:	City:
State:	Zip Code:
Home Phone:	Work Phone:	Cell Phone:
Email:	Birth Date: Now
Driver's License or State ID#:
Employer:	Education:

Personal References

Name:	Number:
Name:	Number:

Work Experience

Name of Organization:	Contact Number:
From: Now	To: Now
Name of Organization:	Contact Number:
From: Now	To: Now

Have you ever pleaded "nolo contendere" to or been convicted or found guilty of a felony?

If yes, please explain:

(Please give date, nature or offense and disposition)

It is mandatory that everyone must attach a medical statement from your doctor declaring that participation as an Auxiliary Officer will not adversly affect your health.

I verify that all information given in this application is true to the best of my ability. I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment as a City of Jacksonville volunteer or for termination after appointment.

Signature:

Date:

Now

The City of Jacksonville encourages persons with disabilities to participate in its programs and activities.
Requests for an accommodation should be submitted to the Disabled Services Division within a reasonable amount of time by contacting:

Kara Tucker
Chief, ADA Coordinator
Disabled Services Division

904-255-5472
karat@coj.net

City of Jacksonville

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