Volunteer Background Information

First Name: ^*

Last Name: ^*

Zip Code: ^*

Any Other Names Used:

Date of Birth: ^*

Enter your date of birth in this format: mm/dd/yyyy

Social Security Number: ^*

Email Address

Provide if you prefer to receive information via email.

Mailing Address: ^*

Apartment/Unit#:

City ^*

State*:

Driver's License State:

D.L. Number:

Address on D.L.:

Name of High School, College, University or Institution of Professional Training where you completed the highest level (GED – provide state):

Campus Name:

Campus City and State:

Name on GED or under which you graduated:

Year(s) Attended:

Year Graduated/GED Completed:

Name as it appears on License/Certification/ Registry:

Type:

State/Region or Issuing Organization:

Country:

Number:

Type:

State/Region or Issuing Organization:

Country:

Number:

*Have you ever been convicted of a crime? (Please attach a separate sheet of paper to provide additional entries)

Yes

Offense:

County:

State:

When:

Offense:

County:

State:

When:

Offense:

County:

State:

When:

Offense:

County:

State:

When:

City:

State:

Date From:

Date To:

City:

State:

Date From:

Date To:

City:

State:

Date From:

Date To:

City:

State:

Date From:

Date To:

Minnesota or Oklahoma applicants or employees only: Please mark an X in the designated field if you would like to receive a free copy of a consumer report if one is obtained by the Company. The report will be mailed to the current address you indicated on this form. ^*

Yes, I have read.

California applicants or employees only: Please mark the following field if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. The report will be mailed to the current address indicated above ^*

Yes, I have read.

California applicants or employees only: By marking an X in the designated field, you will receive and are acknowledging receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. ^*

Yes, I have read.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Client by directly contacting PreCheck Inc. Additionally, please mark this field to receive and acknowledge receipt of a copy of Article 23-A of New York Correction Law. ^*

Yes, I have read.

Maine applicants or employees only: Under Chapter 210 Section 1314 of Maine Revised Statutes, you have the right, upon request, to be informed within 5 business days of such request of whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy.

Massachusetts applicants or employees only: If you ask, you have the right to a copy of any background check report concerning you that the Company has ordered. You may contact the Consumer Reporting Agency for a Copy.

Washington State applicants or employees only: You have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

I have read and understand the above information and assert that all information provided by me is true and accurate.

Your Full Name ^*

Today's Date ^*

Please enter date in this format: mm/dd/yyyy

Additional Requirements

Adult Volunteer Signup Form

If you want to volunteer and take care of sick patients, then you can be part of the St. Mary's Medical Center volunteer...

Volunteer Disclosure & Authorization

Please complete a volunteer disclosure and authorization form if you are interested in volunteering with us.

Volunteer Information

Education

State Law Notices

Additional Requirements

About Us