First Name (Required)

Last Name (Required)

I. Personal Information

Address (Line 1) (Required)

City (Required)

State (Required)

Zip Code (Required)

Home Phone

Cell Phone

E-mail Address (Required)

Volunteer Interests

Fundraising
Special Events/Community Outreach
Interning
Volunteer Guest Speaker

II. Background Checks

Have you EVER been convicted of a misdemeanor or felony crime? (Required)

If yes, give date(s), offense(s), and disposition.

Applicants will be screened for criminal convictions and sanctions through the Bureau of Criminal Investigations, the ND Board of Nursing, Child Abuse Registry, Sexual Offenders Registry Index, and Department of Transportation.

III. Referral Sources

Referred By: (Required)

If employee or other, please be specific

IV. References

Please list three references that you have known for at least 1 year.
Please fill out all information completely.

First Name (Required)

Last Name (Required)

Phone Number (Required)

Company and Address (Required)

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Relationship (Required)

First Name (Required)

Last Name (Required)

Phone Number (Required)

Company and Address (Required)

Relationship (Required)

First Name (Required)

Last Name (Required)

Company and Address (Required)

Relationship (Required)

V. Promotional Materials

I give permission for Development Homes to use any pictures taken of me during volunteer work for the purposes of promoting the program or to be placed in the Recognition Program/Slide. (Required)

I give Development Homes Inc. permission to use my image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of Development Homes. I agree that Development Homes have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with the Development Homes mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release Development Homes and from any and all claims which arise out of or are in any way connected with such use. (Required)

Applicant's Statement

I certify that all answers given by me are true, accurate and complete. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of volunteer opportunities or dismissal from volunteer work regardless of when or how discovered. I acknowledge that I have read and understood the above statements and hereby grant permission to confirm the information supplied on this application by me.

Your electronic signature (Required)

Today's Date (Required)