I certify that I have and will provide information throughout the selection process, including on this application, that is true, correct and complete to the best of my knowledge. I agree to serve any client who is assigned regardless of race, sex, creed or national origin. I understand that I will not be paid for my services as a volunteer.

Race/ethnic, gender & disability

Privacy Statement

You are requested to furnish this information to aid the federal judiciary in reporting on equal employment opportunities. This sheet will not be provided to decision-makers who are evaluating your application. This information will be used in planning and monitoring fair employment practices programs. Furnishing this information is voluntary. Failure to do so will have no effect on your application for employment.

Specific Instructions

Please identify your gender and whether or not you have a disability. The categories below are designed to identify your basic racial and national origin category. If you are of mixed racial and/or national origin, identify yourself by the category with which you most closely identify yourself. Mark the box next to the appropriate category.

Demographics

The Dorchester House Multi Service Center has been certified by the Criminal History Systems Board for access to conviction data and pending criminal case data. As an applicant/employee for the position of  , I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information submitted on this form is correct to the best of my knowledge.

I understand that a criminal record check will be conducted upon my application for a volunteer position, and may periodically be requested during my volunteer engagement. Pending receipt of my criminal record, Dorchester House Multi Service Center may, at its discretion, provide me with a volunteer orientation program and/or a temporary position, neither of which would involve direct or indirect client contact or access to client files. I understand that my continued volunteering is subject to the results of my criminal record investigation and that I may be terminated from volunteering based on the criminal record information, which is received, and which does not comply with the criminal record policy of Dorchester House Multi Service Center.

Applicant/employee information