Thank-you for your interest as a volunteer for the City of Nashua Division of Public Works - Parks and Recreation Department. Kindly complete the following as part of the application process:

1.Read this cover sheet, and sign where indicated. Keep a copy for your records.

2.Complete, sign and date the application.

Thank-you

Thomas Dwane

Recreation Program Manager

I understand and agree that the City of Nashua may accept or reject any applicant for a volunteer position in its sole discretion, at any time, without liability. I agree, if selected, to abide by the rules and regulations applicable to the volunteer position for which I have been selected, as the City may from time to time establish. I understand that in the event the City accepts my application, I acquire no contractual or other rights to keep or maintain that volunteer position, and that the City of Nashua may terminate my services at any time, in its sole discretion, without liability.

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                Signature of Applicant                                                     Date

NAME: _________________________________________________________________

                                        Last                         First                                         Middle

ADDRESS: _____________________________________________________________

                                        #/Street                             City                             Zip Code

HOW LONG AT THIS ADDRESS: _________ HOME PHONE:________________

DATE OF BIRTH: _______/ ______/ ______

POSITION APPLIED FOR: ________________ EVER APPLIED BEFORE?______

HAVE YOU EVER BEEN CONVICTED FOR VIOLATIONS OF ANY LAW OTHER THAN MINOR TRAFFIC VIOLATIONS? _________ IF YES, DESCRIBE: ________________________________________________________________________________________________________________________________________________

LIST ANY ADDITIONAL SKILLS, QUALIFICATIONS: Certificates, coaching, first aid, second language, etc: ________________________________________________________________________________________________________________________________________________

LIST ANY EXPERIENCE WORKING WITH YOUTH: _________________________

Position:________________________ Organization/# of Years:___________________

EXPERIENCE IN (Check Applicable): ___Basketball ___Baseball ___Softball

Years: ______________

REFERENCES (three not related)

NAME ADDRESS PHONE #:

1. ______________________________________________________________________

2.______________________________________________________________________

3. ______________________________________________________________________

I hereby declare the information by me in this application is true, correct, and complete to the best of my knowledge. I understand that, if accepted, any misstatement or omission of fact on this application shall be considered cause for dismissal. I do hereby authorize the City or its agents to receive information regarding my personal character. This disclosure statement must be updated every two years.

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