Thank you
for your interest in 4-H and Cooperative Extension. Please
complete the printable
application and return it to your University of Maine
Cooperative Extension county office.
Name: ______________________________________________________________________________
Last
First
Middle
Mailing
Address: _________________________________________________
Street
City State
Zip
Phone Day:
_____________________ Best time to call: ______________
Evening:
_____________________ Best time to call: _________________
E-mail
Address: _______________________________
Were you in
4-H? ______________________________ If so, where?
__________________________
County/Sate
Have you
ever been a leader? ____ Yes ____ No
If yes how many years? ___________________
Where?
_____________________________________________________________________________
City
County
State
Please use a
separate sheet of paper to explain why you are interested in
a 4-H Volunteer position.
Do you
prefer to work directly with: ( ) youth ( )
adults ( ) both
If you
prefer to work with youth, what grade level(s) do you
prefer?
( )
Pre-school
( ) Intermediate Grades: 6, 7, 8
( ) Primary Grades: 1, 2
( ) Senior Grades: 9, 10, 11, 12
( ) Junior Grades: 3, 4, 5
Previous
work or volunteer experience: (List current or most recent
experience first.)
Employer
or Organization Position Title or Volunteer
Role Year
____________________________________________________________________________________
____________________________________________________________________________________
Skills,
Training, Education
____________________________________________________________________________________
____________________________________________________________________________________
Hobbies
and interests
____________________________________________________________________________________
____________________________________________________________________________________
How did you
hear about the 4-H volunteer program?
________________________________________
____________________________________________________________________________________
References:
List two persons not related to you who have definite
knowledge of your qualifications. Include complete
addresses.
Name:
__________________________ Day Phone:____________________
Address:
____________________________________________________________________________________
Street
City St
Zip
Name:
___________________ Day Phone:____________________________
Address:
____________________________________________________________________________________
Street
City St
Zip
May we
contact other references suggested to us in the course of
contacting the references listed above?
____________________________________________________________________________________
Please note:
Information received from any references will be considered
as part of your application.
Have you
ever been convicted of any crime other than a minor
traffic violation?
If yes,
please describe.
I authorize
contact of listed references. I understand that
misrepresentation or omission of facts requested is cause
for non-appointment or termination as a Cooperative
Extension volunteer. I agree to abide by the expectations
of Cooperative Extension and to fulfill the volunteer
responsibilities to the best of my ability.
Volunteer
Signature
Date
Published
and distributed in furtherance of Acts of Congress on May 8
and June 30, 1914, by the University of Maine Cooperative
Extension, the Land Grant University of the State of Maine
and the U.S. Department of Agriculture cooperating.
Cooperative Extension and other agencies of the U.S.D.A.
provide equal opportunities in programs and employment.
If you are a person with a disability and
will need any accommodations to participate in this program,
please call the county Extension office to discuss your
needs. Please contact us at least 10 days prior to the
event to assure the fullest possible attention to your
needs.
The
University of Maine, U.S. Department of Agriculture, and
local governments cooperating.
8/8/06
For more information on
educational programs in your area, contact your
county Extension office.
