Community Juvenile Arbitration Program Volunteer Arbitrator Appllication

Last Name

First

Middle

SSN
For records check purposes only

Street/P.O. Box

Apt#

City

County

State ---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Race

Sex

DOB
For records check purposes only

Telephone

Email

Have you ever been arrested or convicted of a criminal offense?

Yes

No

Have you ever been investigated, charged or convicted of child abuse, neglect or any other offense involving a child?

Yes

No

Occupation

Name and Address of Employer

Supervisor's Name

Telephone

Names of other Volunteer Organizations to which you belong:

Have you ever been dismissed from any organization as a volunteer?

Yes

No

What do you expect to receive or do by volunteering as an Arbitrator?

How did you hear about our program?

Any children?

Ages

Highest educational level completed:

Grammar School

High School

College

Post Grad

Other

References :

List the name and address of three individuals who are not related and have known you for five years or longer (please include complete mailing address)

I certify that the above information is correct. I also understand that a records check through the State Law Enforcement Division and the State Department of Social Services will be conducted on my application.