If you are interested in volunteering with G-PACT, please complete the following application. Our Volunteer Coordinator will respond to you ASAP and help you determine where you would enjoy working the most. If you have any questions, please contact beenerc@g-pact.org for assistance. We hope to work with you in the near future. 

*Indicates Required Field

PERSONAL...

Title*
First Name*
Last Name*
Street Address*
City*

  State*
Zip*
Country*
Phone*

E-mail*
Fax Number

Additional Contact Number
Are you at least 18 years of age?* Yes
No 

Birthdate

Have you ever been convicted of a crime?

 Yes
No

If yes, please explain.
Note:A conviction does not constitute an automatic bar for employment or volunteer position. All pertinent factors will be considered including nature of crime, rehabilitation success, payment with restitution if necessary, etc. :


EDUCATION & EMPLOYMENT...

Please check all levels of education that you have completed

 High School/G.E.D
Business/Technical School
College
Other (Explain: )

Are you currently employed?

 Yes
No 

If yes, how many hours per week do you work?
If not working, are you? Disabled    
Retired
Other (Explain: )

Have you ever been fired or asked to resign?

 Yes
No

If yes, please explain

Special Skills and qualifications (job-related licenses, honor, awards, special accomplishments)


REFERENCES...

Please provide the names of 2 professional (i.e. Professor, teacher, doctor, lawyer, or other business
acquaintance) and 1 personal reference* of whom you have known one year or longer.

Notify each reference that he/she will be contacted by G-PACT personnel regarding your pending volunteer application.
 

Reference #1

Name
Phone Number
Years Known
Relationship

Reference #2

Name
Phone Number
Years Known
Relationship

Reference #3

Name
Phone Number
Years Known
Relationship



AVAILABILITY...
Please indicate your current available time to volunteer your services to G-PACT 5 hours/week or less
5-10 hours/week
10-20 hours/week
More than 20 hours
Varies significantly each week
Do you have consistent internet access? Yes
No



POSITION...
Department Preferences:
#1 Choice
#2 Choice
#3 Choice
 

What experience, if any, do you have with Gastroparesis?
 

How do you feel G-PACT could benefit for you service as a volunteer?
 
How did you hear about G-PACT?



  		Internet Search
Friend or Family Member
The PACT eNewsletter
Yahoo! Gastroparesis Support Group
Other (Explain: )



IMPORTANT...

In connection with my application for my volunteer position, I understand that all requested information will be kept confidential and that at no time will any G-PACT personnel disclose such information.  I further understand that incomplete applications will not be accepted.  (Please initial here*)

 

I certify that all statements given on this application are true and correct to the best of my knowledge.  I agree that any false statements, which have been given on this application, may be grounds for denial of my volunteer position.

 

I acknowledge that I have read and fully understand the foregoing and that I seek a volunteer position under these conditions.

 

Signature (Type name)* 
Date* 

 


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