Community Conflict Resolution Services of Halton
...resolving community conflicts and promoting positive change

Application Form

Personal Information
Family Name:* First Name:* Middle Name:
Address:
City:* Province: Postal Code:
Phone Number:* Alternate Phone Number: Fax:
E-mail Address:*

Employment
Current Employer: Contact Name: Phone Number:
Address:
City: Province: Postal Code:
Position/Title: Length of Employment: May we contact them?
YesNo
References
First Reference:
Name:* Relationship to You:* Phone Number:*
Address:
City: Province: Postal Code:
E-mail Address:

Second Reference:
Name:* Relationship to You:* Phone Number:*
Address:
City: Province: Postal Code:
E-mail Address:

Additional Information
Languages Spoken other than English: Languages Written other than English:
Education, training and experience in Conflict Resolution (i.e. mediation):
Why are you interested in volunteering with us?*
What skills and strengths do you bring to our organization?
What times or days are you available to volunteer?
Are you interested in sitting on the Board of Directors in a volunteer capacity?
How did you hear about Community Conflict Resolution Services of Halton?

Personal Declaration
I, the undersigned, agree that all information contained within this application is factual and has been completed to the best of my knowledge and ability. I permit Community Conflict Resolution Services of Halton to contact any of my references or employers listed in my application. I further agree to provide, at my cost, a current Police Check upon request.
Signed:* Date:*