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VOLUNTEER FACT SHEET

Thank you for your interest in volunteer service on a Jefferson County Board, Commission or Committee. In order that pertinent information maybe provided to the County Board, you are asked to complete the following online form. If you prefer to complete a hard copy of the form, please mail to Jefferson County 320 S. Main Street Jefferson, WI 53549 or fax (920)675-0068. Press to print a form. Print Blank Form

Use the tab key to move from field to field or by clicking on the field with the mouse to select it. Checkboxes can be selected by using the mouse or by pressing the spacebar on the field. Click the submit/print button below to submit the form to the county and print a copy for your files.
 *required
Date:
*
*Last Name:
*Street Address:
Apartment:
*City: State:
*Zip Code:
Phone Number(s): *Home:
  Other:
Email Address:
Length of Time a
County Resident:		 Year(s): Month(s):
AREA OF INTEREST: Please check the box next to the Board, Commission or Committee or area of greatest interest. See the summary sheet for a brief description of what each board, commission or committee does.
(Check all that apply)
 Description  Description
 Description  Description
 Description  Description
 Description  Description
 Description  Description
 Description  Description
 Description  Description
 Description  Description
If listing more than one, please prioritize your choices.
Why are you interested in
joining this or these particular
Board, Commission and/or
Committees?
VOLUNTEER OR WORK EXPERIENCE:
(Begin with your most recent volunteer or work experience and continue with all past years of experience.
Please send additional information or resume, if available, to the address above or email to tammiej@jeffersoncountywi.gov)
Company Name:
 Address:
 Telephone:
Date Started:(mm/dd/yyyy)
 Date Left:(mm/dd/yyyy)
 Starting position:
Supervisor or Contact for reference:
 Position upon leaving:
Description of duties:
Company Name:
 Address:
 Telephone:
Date Started:(mm/dd/yyyy)
 Date Left:(mm/dd/yyyy)
 Starting position:
Supervisor or Contact for reference:
 Position upon leaving:
Description of duties:
Company Name:
 Address:
 Telephone:
Date Started:(mm/dd/yyyy)
 Date Left:(mm/dd/yyyy)
 Starting position:
Supervisor or Contact for reference:
 Position upon leaving:
Description of duties:
ADDITIONAL EXPERIENCE OR QUALIFICATIONS: List any other experience, skills or qualifications, including hobbies, which you believe should be considered in evaluation your qualifications for volunteering.
Fact Sheets are kept on file for 2 years from date of receipt.
All volunteers will be subject to a criminal background check before their appointment is approved.

revised 1/13/2009

5 2012 Jefferson County