Contact Information First Name * Last Name * Address Line 1 * Address Line 2 City * State * – Select –AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Number Fax Number Cell Number Email Address * Academic History Level of Education: H.S. Diploma/GED Some College College Graduate Are you currently a student? Yes No You are a(n) Undergraduate Student Law Student Graduate Student Other Please fill if selected other above. If yes, please list your major/program: Name of Institution: Volunteer Interests Positions of Interest: (check all that apply) Outreach (making phone calls, writing letters, etc.) Organizing (facilitating town hall meetings or college campus events, etc.) Materials Production (creating postcards, posters, brochures, fact sheets, etc.) Fundraising and Development (researching grant foundations and other funding opportunities) Policy Research (researching statewide and nationwide criminal justice polices and related issues) Data Entry Any other specific interests: List Other Specific Interests: Days, Dates, or Times Available: Approximate hours per week: Possible Start Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 Personal References References #1 (name, relationship, phone) References #2 (name, relationship, phone) Employment History Employment/Volunteer History #1 (employer/organization, address, phone): Employment/Volunteer History #2 (employer/organization, address, phone): Employment/Volunteer History #3 (employer/organization, address, phone):
