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DAY KITCHEN HELP APPLICATION
This application may only be used by persons applying to help cook meals for the campers and staff during Summer Camp 2004.

AUTHORIZATION FOR BACKGROUND CHECK

I authorize Great Lakes Burn Camp, Inc. to conduct a background check with the State police and/or appropriate authorities for the purpose of determining my suitability for volunteer staff with Great Lakes Burn Camp, Inc.


Full Name: First, Middle NAME (not initial) & Last Name


Maiden Name (if N/A, indicate as such)


Street Address


City

   
State                                  Zip


Date of Birth (mm/dd/yyyy)


Social Security Number

     
Driver's License Number       State

   
Home Phone                        Work Phone


Today's Date (mm/dd/yyyy)

ADDITIONAL INFORMATION
Please provide the information below-- submissions will be kept confidential


Email Address

Cell Phone Number    Pager Number

Current Employer

Current Occupation

By pressing the submit button you are "signing" this form and stating that all the information contained within the form are true and accurate to the best of your knowledge.