LaSalle County Medical Reserve Corps Volunteer Application

LaSalle County Medical Reserve Corps Volunteer Application
NAME

First NameMiddle NameLast Name
OTHER NAMES USED (including maiden name)
BIRTHDATE

MonthDayYear
EMAIL
example@example.com
PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DRIVER'S LICENSE OR STATE ID #

NUMBERSTATE ISSUEDEXPIRATION DATE
EMPLOYER
TYPE: HEALTHCARE PROFESSIONAL
OTHER HEALTHCARE PROFESSIONAL (please specify)
HEALTHCARE PROFESSIONAL LICENSE/CERTIFICATION NUMBER
STATE ISSUED
LICENSE/CERTIFICATION EXPRIATION DATE
TYPE: NON-MEDICAL (enter Job Title)
SECOND LANGUAGE
I PREFER TO BE:
WHICH COMMUNTY WOULD YOU PREFER TO SERVE IN?
A Criminal Background Check is required of all volunteers. No sex offense convictions; no drug convictions within last ten (10) years. Past convictions will not necessarily prevent a volunteer from being accepted but will be evaluated on case by case basis.
HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR (other than a traffic violation)?
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
IF YES TO EITHER QUESTION ABOVE, PLEASE EXPLAIN
Signature
Should be Empty: