1
2Form 11 14-1 0
Instructions: Mark 'Y' in appropriate
UNITED STATES
(January 2001)
boxes. For other items, either print or
DEPARTMENT OF THE INTERIOR
type responses. If extra space is needed,
BUREAU OF LAND MANAGEMENT
use item 17.
VOLUNTEER APPLICATION
(Last First Middle)
1. Name
3. Telephone
2. Age
(
)
4. Street Address (include apartment number, if any)
5. City, State, and Zip Code
6. Which general volunteer work categories are you most interested in?
Archaeology
Historical/Preservation
Riparian
Minerals/Geology
Botany
Soil/Watershed
Natural Resources Planning
Trail/Campground Maintenance
Campground Host
Office/Clerical
Tour Guide/Interpretation
Construction/Maintenance
Pest/Disease Contro
l
Visitor Information
Computers
Range/Livestock
Wild Horses
Fire Prevention
Other:
Recreation/Wilderness
Fisheries/Wildlife
Research/Library
Forestry
7. What qualifications/skills/experience/education do you have that you would like to use in your volunteer work?
Drivers License
Backpacking/Camping
Public Speaking
Biology
Research /Librarian
First Aid/CPR Certificates
Boat Operation
Sign Language
Foreign Language:
Supervision
Carpentry
Hand/Power Tools
Clerical/Office Machines
Heavy Equipment Operation
Other Trade Skills
Computer Programming
Teaching
Horses-Care/Riding
Computer Software:
Working with People
Landscaping/Reforestation
Writing/Editing
Land Surveying
Defensive Driving Training
Other
Livestock/Ranching
Drafting/Graphics
Map Reading/Orienteering
Drive Standard Trans.
Mountaineering
Drive 4 x 4s
Photography
8. Based on boxes checked in items 6 and 7, what particular type of volunteer work would you like to do? (Please
describe specific qualifications, skills, experience, or education that apply)
9a. Have you volunteered before ?
Yes
No
9b. If yes, please briefly describe your volunteer experience.
10. Would you be willing to supervise other volunteers?
Yes
No
I 1. What are some of your objectives for working as a volunteer?
(Continued on next page)
Form 11 14-1 0
Instructions: Mark 'Y' in appropriate
UNITED STATES
(January 2001)
boxes. For other items, either print or
DEPARTMENT OF THE INTERIOR
type responses. If extra space is needed,
BUREAU OF LAND MANAGEMENT
use item 17.
VOLUNTEER APPLICATION
(Last First Middle)
1. Name
3. Telephone
2. Age
(
)
4. Street Address (include apartment number, if any)
5. City, State, and Zip Code
6. Which general volunteer work categories are you most interested in?
Archaeology
Historical/Preservation
Riparian
Minerals/Geology
Botany
Soil/Watershed
Natural Resources Planning
Trail/Campground Maintenance
Campground Host
Office/Clerical
Tour Guide/Interpretation
Construction/Maintenance
Pest/Disease Contro
l
Visitor Information
Computers
Range/Livestock
Wild Horses
Fire Prevention
Other:
Recreation/Wilderness
Fisheries/Wildlife
Research/Library
Forestry
7. What qualifications/skills/experience/education do you have that you would like to use in your volunteer work?
Drivers License
Backpacking/Camping
Public Speaking
Biology
Research /Librarian
First Aid/CPR Certificates
Boat Operation
Sign Language
Foreign Language:
Supervision
Carpentry
Hand/Power Tools
Clerical/Office Machines
Heavy Equipment Operation
Other Trade Skills
Computer Programming
Teaching
Horses-Care/Riding
Computer Software:
Working with People
Landscaping/Reforestation
Writing/Editing
Land Surveying
Defensive Driving Training
Other
Livestock/Ranching
Drafting/Graphics
Map Reading/Orienteering
Drive Standard Trans.
Mountaineering
Drive 4 x 4s
Photography
8. Based on boxes checked in items 6 and 7, what particular type of volunteer work would you like to do? (Please
describe specific qualifications, skills, experience, or education that apply)
9a. Have you volunteered before ?
Yes
No
9b. If yes, please briefly describe your volunteer experience.
10. Would you be willing to supervise other volunteers?
Yes
No
I 1. What are some of your objectives for working as a volunteer?
(Continued on next page)
12. Please specify any physical/medical limitations that may influence your volunteer work activities. Include allergies,
medications, etc.:
13a. Which months would you be available for volunteer work?
February
March
April
May
August
January
June
July
September
October
November
December
13b. How many hours per week would you be available for volunteer work'? Hours:
13c. Which days per week would you be available for volunteer work
Tuesday
Wednesday
Thursday
Friday
Saturday
Monday
Sunday
14. Specify at least three states or specific locations within a state where you would like to do volunteer work:
15. Specify your lodging requirements:
I will furnish my own lodging (such as, tent, camper, trailer, own home, relative's or friend's home)
I will require assistance in finding lodging.
16. If a volunteer assignment is not available at the locations specified in item 14, do you want your application forwarded
to another location or Federal agency seeking volunteers your background/interest?
Yes
No
17. This space is provided for more detailed responses. Please indicate the item numbers to which these responses
apply:
18. REFERENCES (include name, address, telephone number and relationship):
1.
2.
3.
4.
NOTICE TO VOLUNTEER
Volunteers are not considered to be, nor are they, federal employees for any purposes other than Federal tort claims, injury compensation, loss
or damage to personal property, and situations involving assaults, threats, and batteries while engaged in the performance of their official duties.
Volunteers are not permitted by Federal law, nor should they be assigned to perform: (1) any law enforcement work (2) any hazardous duty (3)
any work in the policyrnaking process. Volunteers may also be required to undergo background checks, provide requested information, and
authorize the disclosure of information pertaining to themselves for this purpose. Volunteer service does not qualify for Federal leave accrual
or any other benefit. However, volunteer service can be credited as work experience.
PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act (PL 93-579) 5 U.S.C. 301 and 7 CFR 260 authorized acceptance of the
information requested on this form. The data will be used to contact applicants and to interview, screen, and select them for volunteer
assignments. Furnishing this data is voluntary.
Date:
19. Signature: (Sign in ink)
Form 1114-10 (January 2001) (Page 2)
