Education Background:
Current service with other boards/committees:
Past service with other boards/committees:
Motivation for serving:
References: Please provide names, telephone numbers and/or email addresses of two people familiar
with your abilities, knowledge, or work experience
_________________________________________________________________________________
Name Telephone E-mail
_________________________________________________________________________________________
Name Telephone E-mail
Have you ever been convicted of a felony? Yes_____ No_______
If you answered yes, please attach a separate sheet of paper and briefly describe the circumstances
of your conviction. A current charge or conviction will not necessarily disqualify you from becoming a
volunteer, however it may limit where we may place you.
I certify all information contained on this application is true and complete to the best of my knowledge. I
hereby authorize the City of Burlington to investigate any information contained in this application. I
understand that false or misleading statements shall be sufficient grounds for disqualification for the
City's Volunteer Program. Further, I understand that as a Volunteer, I am offering my service of my own
free will without any expectation of compensation, benefits, or insurance of any kind. If selected for a
volunteer position, I agree to abide by the policies and procedures of the City and the Department I
volunteer in. I am aware that I may terminate my volunteer participation at any time and that the City
reserves the right to terminate a volunteer from their duties with or without cause at any time.
Signature: ___________________________________________ Date: ________________________
Please Return Application to: Burlington City Hall, 300 N Pine Street, Burlington, WI 53105
Phone: (262) 342-1161 Fax: (262) 763-3474
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