Community Service Application
Attachment A
VILLAGE OF NORTH PALM BEACH
“THE BEST PLACE TO LIVE UNDER THE SUN”
APPLICATION FOR STUDENT VOLUNTEER COMMUNITY SERVICE
In accordance with the provisions of the Americans w/Disabilities Act (ADA),
this document may be requested in an alternate format.
PLEASE PRINT LEGIBLY IN INK and COMPLETE IN FULL.
Date:
Name:
Street: Apt. #
City: State: Zip Code:
Cell Phone: ( ) Home Telephone: ( )
Are you legally authorized to work in the United States? (Proof will be required)
Yes
No
Are you currently a full-time student?
Yes
No
If “yes”, please state the name of the school, and current student year attending:
Are you related to a current Village Employee?
Yes
No
If “yes”, please state name, relationship, and department employed:
Date available for work:
Days/Times able to work:
Are you able to perform the essential job functions of the position for which you are applying?
(The job description is available for review). Yes No
Do you need any special accommodations to perform the essential functions of this job?
Yes No
501 U.S. HIGHWAY 1, NORTH PALM BEACH, FL 33408---3344
Attachment A
REFERENCES
Name and Mailing Address Occupation Phone w/ Area Code
FOR ALL APPLICANTS:
I hereby certify that the answers given to the foregoing questions and statements are true. I authorize
the Village of North Palm Beach to investigate and verify any or all of the information contained in this
application. I understand that any misrepresentation of facts will be cause for dismissal or may disqualify
me from consideration. Further, I understand and agree that any community service project is for no
definite period and may be terminated without previous notice. I acknowledge and agree that if at any
time I am subjected to any type of discrimination or harassment, I will contact the Director of Human
Resources or other management representative immediately to obtain assistance in the resolution of
such matters. I understand that the Village has an anti-harassment policy and that the complaint
procedure stated within that policy should be utilized. Further, in accordance with Florida Public
Records Law, Chapter 119, F.S., information provided on this application may be “inspected and
examined by any person desiring to do so, at any reasonable time, under reasonable conditions, and
under supervision by the custodian of the public record or his designee”.
Applicant’s Signature Date
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
501 U.S. HIGHWAY 1, NORTH PALM BEACH, FL 33408---3344