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Volunteer Application Form SAINT ANNE CATHOLIC CHURCH Hiring Entity 106 11TH Avenue NE Address Ruskin City FL 33570 State Zip Dear Volunteer Thank you for offering your time and talent at Saint Anne Catholic Church. The policy of the Diocese of St* Petersburg requires questions and return this form to your Volunteer Administrator. Name Suffix Sr. Jr III Date of Birth State Place of Employment Work Phone Home Phone Are you a member of the Catholic Church Number of years in Florida Yes No Zip Your parish name If less than 5 years previous residence outside of Florida Have you previously been screened within the diocese If yes where and when Volunteer position s you are seeking Will you be driving as part of your volunteer work Prior experience working in a parish environment Driver s license Has your license ever been suspended or revoked - over- Race If yes please explain Sex Have you ever been arrested If yes what was the result of the arrest include adjudication withheld and plea of nolo contendere involving an allegation of sexual abuse an intentional tort E*g. assault battery etc* Has your employment ever been terminated for reasons related to allegations of physical abuse Authorization In conjunction with my request to serve as a volunteer for the above position I understand that investigative inquiries on my background are to be made on me to assess whether any reason exists that would suggest that I not be accepted for the position* These inquiries will be made according to policies of the hiring entity and will consist of a criminal background check and/or driving record check using the services of the Diocese of St* Petersburg / Department of Human Resources or a designated outside firm* The information received will be kept confidential and will be used only to determine my suitability to volunteer for the above noted position* I authorize without reservation any party contacted to furnish any or all of the above-mentioned information* Further I will allow a photocopy of this authorization to be as valid as the original for purposes conducting the necessary investigation* In addition I agree to abide by the policies procedures and code of conduct that currently exist or may be amended in the future by the entity for which I am volunteering. Signature of Volunteer Date NOTE Date of birth sex and race are being requested only for purposes of identification in obtaining accurate retrieval of records. The policy of the Diocese of St* Petersburg requires questions and return this form to your Volunteer Administrator. Name Suffix Sr. Jr III Date of Birth State Place of Employment Work Phone Home Phone Are you a member of the Catholic Church Number of years in Florida Yes No Zip Your parish name If less than 5 years previous residence outside of Florida Have you previously been screened within the diocese If yes where and when Volunteer position s you are seeking Will you be driving as part of your volunteer work Prior experience working in a parish environment Driver s license Has your license ever been suspended or revoked - over- Race If yes please explain Sex Have you ever been arrested If yes what was the result of the arrest include adjudication withheld and plea of nolo contendere involving an allegation of sexual abuse an intentional tort E*g.

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