Volunteer Application Form

City of Jacksonville

Disabled Services Division

Volunteer Application

Application for membership as an Auxiliary Parking Enforcement Officer

Last Name, First Name:	Street:	City:
State:	Zip Code:
Home Phone:	Work Phone:	Cell Phone:
Email:	Birth Date: Date and timeNow
Driver's License or State ID#:
Employer:	Education:

Personal References

Name:	Number:
Name:	Number:

Work Experience

Name of Organization:	Contact Number:
From: Date and timeNow	To: Date and timeNow
Name of Organization:	Contact Number:
From: Date and timeNow	To: Date and timeNow

Have you ever pleaded "nolo contendere" to or been convicted or found guilty of a felony?
Have you ever pleaded "nolo contendere" to or been convicted or found guilty of a felony?:

If yes, please explain: If yes, please explain:

(Please give date, nature or offense and disposition)

It is mandatory that everyone must attach a medical statement from your doctor declaring that participation as a Title III Support Officer will not adversly affect your health.

I verify that all information given in this application is true to the best of my ability. I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment as a City of Jacksonville volunteer or for termination after appointment.

Signature:

Date:

Now

The City of Jacksonville encourages persons with disabilities to participate in its programs and activities. Requests for an accommodation should be submitted to the Disabled Services Division within a reasonable amount of time by contacting:
Kevin McDaniel
904-630-4940 (Phone)
904-630-4933 (TTY)
bmeyer@coj.net

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