Volunteer Application Form

Name*

First NameMiddle NameLast Name

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

E-mail*

Employer

Position

Please list special talents or skills you have that you feel could benefit PORTCO.

Availability

Please indicate any physical limitations.

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

As a volunteer of PORTCO, Inc., I agree to abide by the organization’s policies and procedures. I understand that I will be volunteering at my own risk and that PORTCO, its employees and affiliates, cannot assume any responsibility or liability for any accident, injury or health problem which may arise from any volunteer work. I agree that all the work I perform for PORTCO will be on a volunteer basis and I am not eligible to receive compensation or any monetary payment or reward.

If volunteer is a minor, a parent or guardian must agree to the above terms and conditions and sign below.

Signature

Parent/Guardian Signature

I understand that in conjunction with my application to volunteer, PORTCO, INC will use the services of an outside agency to research and verify the information I have provided, including my personal background, character,
professional standing, work history and qualifications. This agency will provide a report to PORTCO, INC. PORTCO, INC uses Backgrounds Online, a consumer-reporting agency as an agent to perform background verifications.

Backgrounds Online will utilize various sources of information it deems appropriate including but not limited to: Department of Motor Vehicle records, criminal conviction records, current and former employers, military records, education records, professional and personal references.

I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above to PORTCO, INC and Backgrounds Online. I request, authorize and consent to the procurement of an Investigative Consumer Report and understand that it may contain information about my background, mode of living, character, personal characteristics and general reputation. This authorization in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit Reporting Act, I will be notified by PORTCO, INC if ability to volunteer is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to PORTCO, INC. I further understand that when requesting a copy of the report, proper identification will be required and I should direct my request to: Backgrounds Online, 1821 Q Street, Sacramento, CA 95814, phone: 800.838.4804.

LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES. I HEREBY RELEASE PORTCO, INC AND ITS
AGENTS, BACKGROUNDS ONLINE AND ALL PERSONS, AGENCIES, AND ENTITIES PROVIDING INFORMATION OR REPORTS ABOUT ME FROM ANY AND ALL LIABILITY ARISING OUT OF THE REQUEST FOR OR RELEASE OF ANY OF THE ABOVE MENTIONED INFORMATION OR REPORTS

Other names you have used or are also known as

First NameLast Name

Please provide all residential addresses for the past 7 years

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Years Lived Here*

Former Address*

Street Address

Street Address Line 2

CityState

Zip Code

Years Lived Here*

Date of Birth*

Date

Social Security Number*

Driver's License Number

License State

Street Address

Street Address Line 2

State

May we contact your current employer?*

YesNo

Would you like a copy of this report?

YesNo

Signature

Volunteer Application

Background Check Release Form