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Brighton Police Department Victim Services Volunteer Application
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First Name
*
Last Name
*
Address1
*
Address2
City
*
State
*
Zip
*
Home Telephone Number:
Cell Phone Number:
Work Phone Number:
Social Security #
*
Date of Birth:
*
Date of Birth:
Personal Information
Please Check Correct Response:
Physical Limitations:
*
-- Select One --
Yes
No
Education:
-- Select One --
Grades 1-12
GED
College
Graduate School
Technical / Vocational
Highest Level Completed - Please Select Correct Response
Most Recent Employer:
List Previous Volunteer Experience:
Have you been asked to resign from any previous employment or volunteer position in the last 3 years?
-- Select One --
Yes
No
(If Yes) Please Explain:
Do you have a valid Colorado Operator's License?
-- Select One --
Yes
No
License #
Expiration Date:
Expiration Date:
Restrictions?
-- Select One --
Yes
No
Have you ever had your driver's license suspended or revoked?
-- Select One --
Yes
No
What type of vehicle insurance do you carry?
Policy #
Languages other than English (Fluent / Read / Write)
Volunteer Availability: (check all applicable):
Shifts are for 12 hours
6:00am - 6:00pm Shift
6:00pm - 6:00am Shift
No Preference
Days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
In a case of an emergency, notify:
First Name
Last Name
Street Number
Street Name
Street Type
Apt #
City
State
Zip
Telephone
Have you ever been convicted of a misdemeanor or a felony?
-- Select One --
Yes
No
Have you ever been charged or convicted of a charge of involving Domestic Violence?
-- Select One --
Yes
No
Pleae mark all that apply to you in regards to your previous/current drug use:
Marijuana use in the last 5 years
Use Marijuana longer than 5 years ago
Other illegal drugs (not including LSD or Marijuana) longer than 5 years ago
LSD
Never used illigal drugs
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