What are the Membership Liability Release issues?

PERSONAL, PROFESSIONAL OR VOLUNTEER REFERENCES

1.  Name ________________________________________________

May we call?   YES   NO

Affiliation, Position or Relationship to You _________________________________________

Home Phone __________________________ Work Phone ____________________________

2.  Name ________________________________________________

May we call?   YES   NO

Affiliation, Position or Relationship to You _________________________________________

Home Phone __________________________ Work Phone ____________________________

Omissions or misrepresentation of information on your application may disqualify you from participation in the Timebank.

Affirmative answers to the following questions will not necessarily disqualify an applicant from participation.

Are you currently on probation or parole?   YES     NO

If “yes” please describe the conviction and list the dates of your probation:

_____________________________________________________________________________________________

Have you ever been convicted of a felony or do you have any pending felony charges?  

YES    NO   If “yes,” please describe _________________________________________________________________________