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Volunteer Application

Volunteer Application

Join our team! Please fill out the form below to be considered for a volunteer position.

Name (First and Last) (required)

Address (required)

City (required)

ZIP Code (required)

County (required)

Phone Number (XXX-XXX-XXXX) (required)

Phone Number Type (required)

Fax Number

Email Address (required)

Sex (required)

Date of Birth (YYYY-MM-DD) (required)

Spouse's Name

Ethnicity/Race (optional)
 White, Non-Hispanic Black or African-American Native American/Alaska Native Asian Hispanic/Latino Other

Employer (if employed)

Occupation (If retired, please note "Retired" and former occupation)(required)

How Did You Hear About CLAIM This website Friend or relative Newspaper or newsletter Employer CLAIM Volunteer/Staff (please list name in "Specify Other" box) AmeriCorps Member (please list name in "Specify Other" box) Other

Specify Other

Positions I Am Interested
 Counselor Leader in Outreach Administrative Support Interest Specialist Mentor AmeriCorps Member

CLAIM volunteers cannot work for insurance companies, have an insurance license and/or sell insurance for at least one year prior to volunteering. A person cannot potentially receive any financial gain from becoming a CLAIM volunteer counselor.

Are you currently working in the insurance industry?(required)

If no, have you in the past 12 months?(required)

If yes, what were your responsibilities?


Community Service

Reasons for Wanting to Volunteer (required)

Would you be willing to make a minimum commitment of six hours/month for six month?(required)

Language Skills

Have you ever been convicted of a felony?
(A Yes answer is not an automatic disqualification. A background check will be completed during training)(required)

If yes, please briefly explain.


Please list three references (Name, Phone Number and Relation).

Reference One (required)

Reference Two (required)

Reference Three (required)