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Volunteer Application

Kentucky Cooperative Extension Service

Volunteer Application And Background Check

Kentucky Cooperative Extension Service takes seriously its obligation to provide a safe environment for all persons involved in volunteer activities. This application will gather information necessary to successfully match the applicant with the appropriate position. When questions arise about qualifications, answers given by the application will be verified.

First Name*

Middle Name*

Last Name*

Email*

Primary Phone*

Mobile Phone*

Work phone

Other phone

Mailing Address: *

City*

State*

Zip*

Residential address if different than above

City

State

Zip

How long have you lived at present address*

If less than five years, list your prior addresses and the length of time you lived at each.

Street, Box, Route, Apt #

City

State

Zip

Length of Stay

Street, Box, Route, Apt #

City

State

Zip

Length of Stay

Ethnicity*

AHispanic or Latino

BNot Hispanic or Latino

Racial Groups*

AWhite

BBlack or African American

CAmerican Indian or Alaskan Native

DAsian

ENative Hawaiian or Other Pacific Islander

Gender*

AFemale

BMale

COther

Occupation*

Employer*

If you were a 4-Her, indicate County*

State*

If you have volunteered with youth (any organization), how long

If yes, list City

County

State

Convicted of two or more moving vehicle violations in the last 12 months*

AYes

BNo

If yes, please explain

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