Date:

Address:     [apt. #]:

City:     State:     Zip Code:

Phone Number: ()-

Email address:

Emergency Contact: Phone:()-

Accommodation Needed?


Languages Spoken: Spanish French Asian (type) Sign Other

Volunteer Background: Please attach resume also, if available

Referral (How did you find us?):

Comments:

Typing/keyboarding Words Per Minutes

Computer Skills: MS Word MS Access (Data Entry) Other:

Clerical Support:

Receptionist:

Bulk Mail Preparation:

Research (describe):

Transcibing (documents, audio recording, Braille):

Reading/Writing (correspondence, etc. for those with visual disabilities:

Systems Advocacy (phoning, letter writing, speaking or arranging for speakers, support in organizing events, etc.):

Field Surveys (training and mileage reimbursement provided):

Public Relations:

Peer Support (Must have a disability): :

Fundraising:

Photography:

Accounting:

Legal services:

Carpentry/Handyman:

Interpreting - describe languages and level of skill:


Other:

I certify that the facts set forth in this Application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements may result in my dismissal I authorize PIRS to make an investigation of any of the facts set forth in this application.