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Brighton Police Department Victim Services Volunteer Application

2. First Name*

3. Last Name*

5. Address1*

7. Address2

9. City*

10. State*

11. Zip*

13. Home Telephone Number:

14. Cell Phone Number:

15. Work Phone Number:

17. Social Security #*

18. Date of Birth:*
    Date of Birth:

22. Personal Information
    Please Check Correct Response:

    Please Check Correct Response:

23. Physical Limitations:*
    -- Select One --YesNo

25. Education:
    -- Select One --Grades 1-12GEDCollegeGraduate SchoolTechnical / Vocational

    Highest Level Completed - Please Select Correct Response

26. Most Recent Employer:

27. List Previous Volunteer Experience:

29. Have you been asked to resign from any previous employment or volunteer position in the last 3 years?
    -- Select One --YesNo

30. (If Yes) Please Explain:

34. Do you have a valid Colorado Operator's License?
    -- Select One --YesNo

35. License #

36. Expiration Date:
    Expiration Date:

38. Restrictions?
    -- Select One --YesNo

39. Have you ever had your driver's license suspended or revoked?
    -- Select One --YesNo

41. What type of vehicle insurance do you carry?

42. Policy #

46. Languages other than English (Fluent / Read / Write)

50. Volunteer Availability: (check all applicable):

52. Shifts are for 12 hours

    1. 6:00am - 6:00pm Shift

    1. 6:00pm - 6:00am Shift

    1. No Preference

54. Days:

    1. Sunday
    2. Monday

    1. Tuesday
    2. Wednesday

    1. Thursday
    2. Friday

    1. Saturday

59. In a case of an emergency, notify:

61. First Name

62. Last Name

64. Street Number

65. Street Name

66. Street Type

67. Apt #

69. City

70. State

71. Zip

73. Telephone

77. Have you ever been convicted of a misdemeanor or a felony?
    -- Select One --YesNo

79. Have you ever been charged or convicted of a charge of involving Domestic Violence?
    -- Select One --YesNo

81. Pleae mark all that apply to you in regards to your previous/current drug use:

    1. Marijuana use in the last 5 years
    2. Use Marijuana longer than 5 years ago
    3. Other illegal drugs (not including LSD or Marijuana) longer than 5 years ago
    4. LSD
    5. Never used illigal drugs

Leave This Blank:


83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit Submit and Print

* indicates a required field