COMMUNITY JUVENILE ARBITRATION PROGRAM

VOLUNTEER ARBITRATOR APPLICATION FORM

Name_______________________________________________________     _______________________________

                                Last                        First                        Middle                                         *Social Security Number

*(for records check purposes only)

Address_______________________________________________________________________________________

                                                                                Street, P. O. Box or Route Number

_____________________________________________________________________________________________

                City                                         County                                                   State                                       Zip

*Sex ________    *Race ___________          *Date of Birth__________________ *(for records check purposes only)

Telephone__________________________                Email Address_____________________________________________

Have you ever been arrested or convicted of a criminal offense? _____Yes  _____No

Have you ever been investigated, charged or convicted of child abuse, neglect or any other offense involving a

child? _____Yes  _____No  If yes, please explain:_____________________________________________________

Occupation:          ______________________________________________________________________________

Name and Address of Employer___________________________________________________________________

Supervisor’s Name_________________________________________               Telephone___________________________

Names of other Volunteer Organizations to which you belong ___________________________________________

_____________________________________________________________________________________________

Have you ever been dismissed from any organization as a volunteer? _____Yes   _____No

If yes, please explain:___________________________________________________________________________

What do you expect to receive or do by volunteering as an Arbitrator? ____________________________________

_____________________________________________________________________________________________

How did you hear about our program? ______________________________________________________________

Any children? _________                 Ages _____________________________

Highest educational level completed:  __Grammar School   __ High School   __ College   __ Post Grad   __ Other

References – List the name and address of three individuals who are not related and have known you for five years or longer (please include complete mailing address):

1.____________________________________________________________________________________________

2.____________________________________________________________________________________________

3.____________________________________________________________________________________________

I certify that the above information is correct.  I also understand that a records check through the State Law Enforcement Division and the State Department of Social Services will be conducted on my application.

____________________                 ________________________________________________________________

                Date                                                                                                        Signed

Please return to:

Noah J. R. Moore, Program Director

101 Meeting Street, Suite 330

Charleston, South Carolina 29401

843-958-5150 / 843-958-5160 (fax)