Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date or Birth *

MM

DD

YYYY

Emergency Phone *

(###)

###

####

If So, When?

MM

DD

YYYY

Have you ever been convicted of a criminal offense? *

Yes

No

Have you ever been charged with neglect, abuse, or assault? *

Yes

No

Has your driver's license ever been suspended or revoked in any state? *

Yes

No

Do you use illegal drugs? *

Yes

No

Do you have any physical limitations which might limit your ability to perform certain types of work? *

Yes

No

Are you willing to commit to the full 44 hours of training class plus apprentice shifts followed by at least one year of volunteer service to ContactLifeline (volunteering 8 hours per month) and mandatory Advanced Training sessions quarterly? *

Yes

No

Reference Name 1 *

First Name

Last Name

Reference Phone 1

(###)

###

####

Reference Name 2

First Name

Last Name

Reference Phone 2

(###)

###

####

I have read and agree with the statement below: *

Agree