Capital EX

*First Name

Middle Name

*Last Name

*Address

*City

*Province

---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

*Postal Code

*Phone

*Email

*Gender

 Female Male

*Have you ever been employed by Northlands before?

 Yes No

*Have you volunteered at Northlands before?

 Yes No

*Are you a student?

 Yes No

*How did you hear about us?

---Volunteer FairWebsiteFriendNewspaperAt a Northlands EventTV / RadioOther

*Are you retired?

 Yes No

*Are you employed?

 Yes No

If you are employed, please complete the employment section:

Current Employer

Occupation

Employer Address

Employer Email

Employer City

Employer Phone

Emergency Contact:

*Name

*Phone

*Day Phone

*Evening Phone

*Relationship To You

Two non–family references whom we may contact:

*Name

*Day Phone

*Evening Phone

*Name

*Day Phone

*Evening Phone

Northlands is committed to the protection of your privacy. Northlands collects and uses your personal information to provide you with information on relevant products, services, and special offers that may be of benefit to you.

By providing contact information such as full name, postal address, phone number, or e-mail address, you consent to the collection, use, and disclosure of your personal information by Northlands for these purposes only, unless you indicate otherwise to us in writing.

Details of Northlands’ privacy policy are available online at northlands.com, or in printed form by request.

* I agree

 Yes No

I hereby allow Northlands to perform a check of my background, including police records, driving record, past employment / volunteer history, educational / professional status, personal references and other persons or sources as appropriate for the volunteer jobs available at Northlands.

I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from consideration for volunteer work. I understand that information collected during this background check will be limited to that appropriate to determining my suitability for volunteer work at Northlands and that all such information collected during the check will be kept confidential.

I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability for volunteer work at Northlands and such other information as they deem appropriate.

* I agree to allow Northlands to do a background check

 Yes No

I verify that the statements in this volunteer application form are true. I understand and agree that a false statement may disqualify me from volunteering. I agree to abide by Northlands policies and regulations and to keep all information learned in the course of my volunteering at Northlands confidential.

* I agree to the conditions stated above

 Yes No

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