SENIOR COMPANION PROGRAM (SCP)/FOSTER GRANDPARENT PROGRAM (FGP)</tit= le> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"country-region"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"PlaceType"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"PlaceName"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"Street"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"PostalCode"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"City"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"address"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"State"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"place"/>  <style>  </style>  </head> <body lang=3DEN-US style=3D'tab-interval:.5in'> <div class=3DSection1> SENIOR COMPANION PROGRAM (SCP)/FOSTER GRANDPARENT PROGRAM (FGP)<o:p= ></o:p> OF NORTHERN & CENTRAL <st1:State w:st=3D"on"><st1:place w:st=3D= "on">ARIZONA</st1:place></st1:State><o:p></o:p> APPLICATION & ENROLLMENT FORM (Substitute W-9)<o:p></o:p></= p> <st1:place = w:st=3D"on">PO</st1:place> <st1:address w:st=3D"on"><st1:Street w:st=3D"on">BOX 5063</st1:Str= eet>, <st1:City w:st=3D"on">FLAGSTAFF</st1:City>, <st1:State w:st=3D"on">AZ</st1:State> <s= t1:PostalCode w:st=3D"on">86011-5063</st1:PostalCode></st1:address><o:p></o:p> PHONE: (928)523-3560; FAX: (928)523-9189; TOLL FREE; (866) 856-3017= <o:p></o:p> <o:p> </= o:p> Date of Application: ____________ = Please circle the program for which you are applying: SCP &= nbsp; FGP<o:p></o:p> <o:p> </= o:p> Name: ___________________________________________Other= Name or Other Alias in_______________ &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; </spa= n>Last 7 Years = Mailing Address: _____________________________________= ______________________________________ &nbs= p; = (City) &n= bsp; = ; &n= bsp; = ; (State) &= nbsp; (Z= ip)<o:p></o:p> Telephone: __________________________________ Message Number: ______________________________<o:p></o:p> </spa= n> &= nbsp; &nbs= p; &= nbsp; = <o:p></o:p> Social Security or Tax Identification #:______________= ____ Gender: ______ Date of Birth: ______________ <o:p> </o:p> Please circle whether you drive and can provide your own transportation: &nbs= p; Yes &= nbsp; No<o:p></o:p><= /b> Drivers License Number & Expiration Date: ______________________________________________________ <o:p> </o:p> Languages spo= ken other than English: ___________________________________________________= _____ <o:p> </o:p> Other experie= nce relating to SCP or FGP and why you would like to become an SCP/FGP voluntee= r: ___________________________________________________________________________= _______________ _________________________________________________________________= _________________________ Please circle your volunteer preferen= ce time: &n= bsp; Morning &= nbsp; Afternoon No Preference<o:p></o:p> <o:p> </o:p> <![if !vml]><img width=3D656 height=3D4 src=3D"ApplicationFormSCP-FGPwebpage_files/image001.gif" v:shapes=3D"_x0000= _s1026"><![endif]> <o:p> </= o:p> Number of peo= ple living in your household including yourself: ______________________________= ______<o:p></o:p> MONTHLY INCOME (confidential). Include all sources and amounts for yourself & others living in = your household: Social Security = ; _________________ &= nbsp; &= nbsp; SSI &= nbsp; &nbs= p; &= nbsp; _________________ Pension/Retirement &= nbsp; ________= _________ &= nbsp; Net Rent (paid to you) &= nbsp; ______________= ___ Saving Account Interest &nb= sp; _________________ &= nbsp; Stocks/Bonds &= nbsp; &nbs= p; _________________ Salary or Wages = ; &n= bsp; _________________ &= nbsp; Other &= nbsp; &nbs= p; &= nbsp; _________________ &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Total Monthly Income_________________= <o:p></o:p> <o:p> </o:p> &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Total Monthly Income x 12 Months =3D<= /b>_______________ <o:p> </o:p> <![if !vml]><img width=3D656 height=3D4 src=3D"ApplicationFormSCP-FGPwebpage_files/image001.gif" v:shapes=3D"_x0000= _s1030"><![endif]> <o:p> </o:p> Please list two character references that are NOT related to you. We WILL be contacting each reference listed: Name &= nbsp; &nbs= p; Address &= nbsp; &nbs= p; &= nbsp; City/State &= nbsp; </s= pan>Zip &= nbsp; Phone # <![if !supportLists]= >1.&n= bsp; = ; <![endif]>___________________________________________________= _________________________________ <o:p> </o:p> <![if !supportLists]= >2.&n= bsp; = ; <![endif]>___________________________________________________= _________________________________ <o:p> </o:p= > </div> <span style=3D'font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Time= s New Roman"; mso-fareast-font-family:"Times New Roman";mso-ansi-language:EN-US;mso-farea= st-language: EN-US;mso-bidi-language:AR-SA;layout-grid-mode:line'> <div class=3DSection2> Emergency Con= tact Name: ____________________________ Address: _____________________________ City/State: _____________________________________Zip: ____________Phone No.: _________________ Relationship to you:&= nbsp; _____________________________ <o:p> </o:p> Insurance Beneficiary:<o:p></o:p> You MUST</= u> name a beneficiary for OUR<= /b> insurance carrier in case of accidental death or dismemberment while volunteering: Name: _________________________________________Address= :____________________________________ City/State: _____________________________________Zip: ____________Phone No.: _________________ <o:p> </o:p> <![if !vml]><img width=3D624 height=3D4 src=3D"ApplicationFormSCP-FGPwebpage_files/image002.= gif" v:shapes=3D"_x0000_s1028"><![endif]> <o:p> </o:p> Addresses for= past seven years, other than current address:<o:p></o:p> Street Address &= nbsp; &nbs= p; &= nbsp; &nbs= p; City/State &= nbsp; </s= pan>Zip Code = ; &n= bsp; From To ______________________________________________________= ____________________________________ ______________________________________________________= ____________________________________ <o:p> </o:p> <h1>Employment History:</h1> Company Name & Address &nb= sp; = </= span>Job Title &nbs= p; &= nbsp; Supervisor &= nbsp; <u= >From To ______________________________________________________= ____________________________________ ______________________________________________________= ____________________________________ <o:p> </o:p> Have you ever= been convicted of anything other than minor traffic violations? &n= bsp; YES &= nbsp; NO<o:p></o:p> If yes, please explain: ________________________________________________________________________ ______________________________________________________= ___________________________________ <o:p> </o:p> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi= dth=3D651 style=3D'width:488.4pt;border-collapse:collapse;border:none;mso-border-alt= :solid windowtext .5pt; mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid windowte= xt; mso-border-insidev:.5pt solid windowtext'> <tr style=3D'height:.25in'> <td width=3D651 colspan=3D3 style=3D'width:488.4pt;border:solid windowtex= t 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.= 25in'> I fully underst= and that, if accepted into either the Senior Companion or Foster Grandparent Program, I am a volunteer in the program and not an employee of <st1:Plac= eName w:st=3D"on">Northern</st1:PlaceName> <st1:PlaceName w:st=3D"on">Arizona</= st1:PlaceName> <st1:PlaceType w:st=3D"on">University</st1:PlaceType> or the State of <st= 1:State w:st=3D"on"><st1:place w:st=3D"on">Arizona</st1:place></st1:State>. Also, as a volunteer, I realize = that I receive a tax-free stipend and not a taxable wage for my volunteer effort= s. If I drive, I certify that I am covered and will maintain the <st1:place w:st=3D"on"><st1:PlaceName w:st= =3D"on">Arizona</st1:PlaceName> <st1:PlaceType w:st=3D"on">State</st1:PlaceType></st1:place> minimum automobile liability insurance.<o:p>= </o:p> </td> </tr> <tr style=3D'height:.25in'> <td width=3D651 colspan=3D3 style=3D'width:488.4pt;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt;height:.25in'> I hereby certif= y that under penalty of perjury that the answers given above is true and correct= to the best of my knowledge and belief and agree to have a background check completed. <o:p></o:p> </td> </tr> <tr style=3D'height:.25in'> <td width=3D651 colspan=3D3 style=3D'width:488.4pt;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt;height:.25in'> Applicant Certification, un= der penalties of perjury, I certify that:<o:p></o:p> <![if !supportLists]>a. </s= pan><![endif]>The number shown on this form is my correct taxpayer identification number (social security number).<o:p></o:p></span= > <![if !supportLists]>b. &nbs= p; <![endif]>I am not subject to backup withholding.<o:p></o= :p> <![if !supportLists]>c. &nbs= p; <![endif]>I am a person residing in the <st1:country-regi= on w:st=3D"on"><st1:place w:st=3D"on">u.s.</st1:place></st1:country-region><= o:p></o:p> </td> </tr> <tr style=3D'mso-yfti-lastrow:yes;height:.4in'> <td width=3D161 valign=3Dbottom style=3D'width:120.85pt;border:none;mso-b= order-top-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.4in'> Signature: <o:p></o:p></spa= n> <o:p> </o:p> ___________________________= __________________________________<o= :p></o:p> </td> <td width=3D161 valign=3Dbottom style=3D'width:120.9pt;border:none;mso-bo= rder-top-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.4in'> <o:p> </o:p> </td> <td width=3D329 valign=3Dtop style=3D'width:246.65pt;border:none;mso-bord= er-top-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.4in'> Date: <o:p></o:p> <o:p> </o:p> ___________________________= _________________<o:p></o:p> </td> </tr> </table> I have viewed an official p= icture Identification Card for the person listed on this application. The Picture ID Card I viewe= d was a ____Driver’s Lice= nse &= nbsp; _____State of AZ Picture ID &nb= sp; _____Passport ID </span= >____Other—please identify:_______________________________________= __________ <o:p> </o:p> Volunteer Coordinator Signa= ture:________________________________________Date:________= __________ <o:p> </o:p> <o:p> </o:p> FOR OFFICE USE ONLY: &= nbsp; ENROLLMENT DATE: ______________________ &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; VOLUNTEER STATION: ____________________ TRAINING COMPLETED: ___________________ <![if !vml]> <table cellpadding=3D0 cellspacing=3D0> <tr> <td width=3D682 height=3D141 style=3D'vertical-align:top'><![endif]><![if= !mso]> <table cellpadding=3D0 cellspacing=3D0 width=3D"100%"> <tr> <td><![endif]> <div v:shape=3D"_x0000_s1029" style=3D'padding:0pt 0pt 0pt 0pt' class= =3Dshape> <div style=3D'mso-element:para-border-div;border:solid white 1.0pt; mso-border-alt:solid white .75pt;padding:0in 0in 0in 0in'> <![if !vml]><img width=3D678 height=3D137 src=3D"ApplicationFormSCP-FGPwebpage_files/image004.gif" v:shapes=3D"_x= 0000_i1025"><![endif]> </div> </div> <![if !mso]></td> </tr> </table> <![endif]><![if !mso & !vml]> <![endif]><![if !vml]></td> </tr> </table> <![endif]>DIRECTOR SIGNATURE: ___________________ &= nbsp; &= nbsp; 1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 <o:p> </o:p> <h2 align=3Dleft style=3D'text-align:left'><o:p> </o:p></h2> <h2>RELEASE AND AUTHORIZATION</h2> <o:p> </o:p> <o:p> </o:p> In connection with this req= uest, I authorize all corporations, companies, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts, military services and persons to release information they m= ay have about me to the person or company with which this form has been filed,= or their agent, Fidelifacts, 3030 N. Central Ave., Ste. 502, Phoenix, Arizona = and releases all parties involved from any liability and responsibility for doi= ng so. <o:p> </o:p> I also authorize the procur= ement of an investigative consumer report and understand that it may contain informa= tion about my backgrounds, mode of living, character, and personal reputation.<s= pan style=3D'mso-spacerun:yes'> This authorization, in original or= copy form, shall be valid for this and any future reports or updates that maybe requested. Further informatio= n may be available upon written request within a reasonable period of time. <o:p> </o:p> I authorize the <st1:PlaceN= ame w:st=3D"on">National</st1:PlaceName> <st1:PlaceName w:st=3D"on">Personnel</= st1:PlaceName> <st1:PlaceName w:st=3D"on">Records</st1:PlaceName> <st1:PlaceType w:st=3D"o= n">Center</st1:PlaceType>, <st1:place w:st=3D"on"><st1:City w:st=3D"on">St. Louis</st1:City>, <st1:Sta= te w:st=3D"on">Missouri</st1:State></st1:place> or other custodian of my mili= tary records to release to Fidelifacts/Phoenix information or photocopies of my military records, or only the following information/records: ____________________________________________________________________= ____ ___________________________= ______________________________________________________________ <o:p> </o:p> Service #: __________________________________ Branch of Service: __________________ <o:p> </o:p> From: _______________To: __________________ <o:p> </o:p> <o:p> </o:p> <o:p> </o:p> ___________________________= ___________________________________________________ APPLICANT’S SIGNATURE= &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; </s= pan>DATE <o:p> </o:p> </div> </body> </html> ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image001.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODdhkAIEAHcAACH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACwAAAAAkAIEAIAAAAAB AgMCNISPqcvtD6OctNqLs968+w+G4kiW5omm6sq27gvH8kzX9o3n+s73/g8MCofEovGITCqXyAIA Ow== ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image002.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODdhcAIEAHcAACH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACwAAAAAcAIEAIAAAAAB AgMCM4SPqcvtD6OctNqLs968+w+G4kiW5omm6sq27gvH8kzX9o3n+s73/g8MCofEovGITCofBQA7 ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image003.wmz Content-Transfer-Encoding: base64 Content-Type: image/x-wmz H4sIAAAAAAACC7t+9tgsBoY3/+N+ZsuIMOxmYQCCdE9GBk4GBuYQIJuJQQIkxMAKxNxMcT/f/Aex eJi2sdXLgBSzMYLVMvxiYgWr+///P4MSA0hGl5EBKsPGwMMAATAZRrCpqsxcDKoMt/9D8PSfIGwk A8O3/4MwTB5mIoj+ANTPzAADAPyY8BjCAAAA ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image004.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhpgKJAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAgABgCY AoAAgAAAAAAAAAL/jI+py+0Po5y02ouz3rz7D4biSJbmeQLqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpdIA/MJjUqn1Kr1is1qt9ycswsOi8fksvmMTl+/6rb7DY/L53Q4u47P6/f8vr999yc4SFho eGgYiLjI2Oj4CKmkGElZaXmJWTiZydnp+QmKtRlKWmp6ihozmsra6vrKuAo7S1trqyZ7q7vL28uU 6xssPEwsA1yMnKxce7zs/Azt2RxNXW19OH2tvc0tl90NHi7e9T1ufo4uGZDO3u7+u/4uP0+/U16P nz9+r9/vX83vn8CBxQISPIjwlsGEDBumWugwosROECdavPioIsaN/xwHaewIMmSdjyJLmkxD8qTK leTisXwJc07KmDRrNnFpM6dOLjN3+vxZoyfQoURXCC2K1OfRpExrLm0KleXTqFRLTq2KlePVrFwn bu0KluHXsGQHji2LVt/ZtGznrW0Ll93buHT34ayLt+PcvHyt7e0L+NnfwISRDS6MONjhxIx1LW4M edbjyJRZTa6MudTlzJyl3e0Mmtvm0KQjjS6NOtbn1KyTnW4N+8/r2LT1zK6NW+bq3Lxh3e4NHM3v 4MTHDC+OnOfu5MwzHW8Ofcrz6NThVb9eaTr27UO0c//uwzv48V6Wkz9PRzz69TDUs39v1Dz8+WXc 019v//75/PrH867v/91/AG4n4IDXFWggdQgmCN2CDDLn4IPIRSghcRRWCNyFGPKm4Ya4deghbSCG CNuIJLJm4omopagiaSy2CNqLMHIm44yY1WgjZTjmCNmOPDLm44+IBSkkYUQWCdiRSPKl5JJ4Nekk XVBGCdeUVLJl5ZVoZaklWVx2CdaXYHIl5phYlWkmVWimCdWabDLl5ptIxSknUXTWCRQKeu7JZ59+ /glooIIOSmihhh6KQQEAOw== ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/filelist.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" <xml xmlns:o=3D"urn:schemas-microsoft-com:office:office"> <o:MainFile HRef=3D"../ApplicationFormSCP-FGPwebpage.htm"/> <o:File HRef=3D"image001.gif"/> <o:File HRef=3D"image002.gif"/> <o:File HRef=3D"image003.wmz"/> <o:File HRef=3D"image004.gif"/> <o:File HRef=3D"filelist.xml"/> </xml> ------=_NextPart

MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C73A22.2EF2ED80" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" SENIOR COMPANION PROGRAM (SCP)/FOSTER GRANDPARENT PROGRAM (FGP)</tit= le> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"country-region"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"PlaceType"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"PlaceName"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"Street"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"PostalCode"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"City"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"address"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"State"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"place"/>  <style>  </style>  </head> <body lang=3DEN-US style=3D'tab-interval:.5in'> <div class=3DSection1> SENIOR COMPANION PROGRAM (SCP)/FOSTER GRANDPARENT PROGRAM (FGP)<o:p= ></o:p> OF NORTHERN & CENTRAL <st1:State w:st=3D"on"><st1:place w:st=3D= "on">ARIZONA</st1:place></st1:State><o:p></o:p> APPLICATION & ENROLLMENT FORM (Substitute W-9)<o:p></o:p></= p> <st1:place = w:st=3D"on">PO</st1:place> <st1:address w:st=3D"on"><st1:Street w:st=3D"on">BOX 5063</st1:Str= eet>, <st1:City w:st=3D"on">FLAGSTAFF</st1:City>, <st1:State w:st=3D"on">AZ</st1:State> <s= t1:PostalCode w:st=3D"on">86011-5063</st1:PostalCode></st1:address><o:p></o:p> PHONE: (928)523-3560; FAX: (928)523-9189; TOLL FREE; (866) 856-3017= <o:p></o:p> <o:p> </= o:p> Date of Application: ____________ = Please circle the program for which you are applying: SCP &= nbsp; FGP<o:p></o:p> <o:p> </= o:p> Name: ___________________________________________Other= Name or Other Alias in_______________ &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; </spa= n>Last 7 Years = Mailing Address: _____________________________________= ______________________________________ &nbs= p; = (City) &n= bsp; = ; &n= bsp; = ; (State) &= nbsp; (Z= ip)<o:p></o:p> Telephone: __________________________________ Message Number: ______________________________<o:p></o:p> </spa= n> &= nbsp; &nbs= p; &= nbsp; = <o:p></o:p> Social Security or Tax Identification #:______________= ____ Gender: ______ Date of Birth: ______________ <o:p> </o:p> Please circle whether you drive and can provide your own transportation: &nbs= p; Yes &= nbsp; No<o:p></o:p><= /b> Drivers License Number & Expiration Date: ______________________________________________________ <o:p> </o:p> Languages spo= ken other than English: ___________________________________________________= _____ <o:p> </o:p> Other experie= nce relating to SCP or FGP and why you would like to become an SCP/FGP voluntee= r: ___________________________________________________________________________= _______________ _________________________________________________________________= _________________________ Please circle your volunteer preferen= ce time: &n= bsp; Morning &= nbsp; Afternoon No Preference<o:p></o:p> <o:p> </o:p> <![if !vml]><img width=3D656 height=3D4 src=3D"ApplicationFormSCP-FGPwebpage_files/image001.gif" v:shapes=3D"_x0000= _s1026"><![endif]> <o:p> </= o:p> Number of peo= ple living in your household including yourself: ______________________________= ______<o:p></o:p> MONTHLY INCOME (confidential). Include all sources and amounts for yourself & others living in = your household: Social Security = ; _________________ &= nbsp; &= nbsp; SSI &= nbsp; &nbs= p; &= nbsp; _________________ Pension/Retirement &= nbsp; ________= _________ &= nbsp; Net Rent (paid to you) &= nbsp; ______________= ___ Saving Account Interest &nb= sp; _________________ &= nbsp; Stocks/Bonds &= nbsp; &nbs= p; _________________ Salary or Wages = ; &n= bsp; _________________ &= nbsp; Other &= nbsp; &nbs= p; &= nbsp; _________________ &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Total Monthly Income_________________= <o:p></o:p> <o:p> </o:p> &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Total Monthly Income x 12 Months =3D<= /b>_______________ <o:p> </o:p> <![if !vml]><img width=3D656 height=3D4 src=3D"ApplicationFormSCP-FGPwebpage_files/image001.gif" v:shapes=3D"_x0000= _s1030"><![endif]> <o:p> </o:p> Please list two character references that are NOT related to you. We WILL be contacting each reference listed: Name &= nbsp; &nbs= p; Address &= nbsp; &nbs= p; &= nbsp; City/State &= nbsp; </s= pan>Zip &= nbsp; Phone # <![if !supportLists]= >1.&n= bsp; = ; <![endif]>___________________________________________________= _________________________________ <o:p> </o:p> <![if !supportLists]= >2.&n= bsp; = ; <![endif]>___________________________________________________= _________________________________ <o:p> </o:p= > </div> <span style=3D'font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Time= s New Roman"; mso-fareast-font-family:"Times New Roman";mso-ansi-language:EN-US;mso-farea= st-language: EN-US;mso-bidi-language:AR-SA;layout-grid-mode:line'> <div class=3DSection2> Emergency Con= tact Name: ____________________________ Address: _____________________________ City/State: _____________________________________Zip: ____________Phone No.: _________________ Relationship to you:&= nbsp; _____________________________ <o:p> </o:p> Insurance Beneficiary:<o:p></o:p> You MUST</= u> name a beneficiary for OUR<= /b> insurance carrier in case of accidental death or dismemberment while volunteering: Name: _________________________________________Address= :____________________________________ City/State: _____________________________________Zip: ____________Phone No.: _________________ <o:p> </o:p> <![if !vml]><img width=3D624 height=3D4 src=3D"ApplicationFormSCP-FGPwebpage_files/image002.= gif" v:shapes=3D"_x0000_s1028"><![endif]> <o:p> </o:p> Addresses for= past seven years, other than current address:<o:p></o:p> Street Address &= nbsp; &nbs= p; &= nbsp; &nbs= p; City/State &= nbsp; </s= pan>Zip Code = ; &n= bsp; From To ______________________________________________________= ____________________________________ ______________________________________________________= ____________________________________ <o:p> </o:p> <h1>Employment History:</h1> Company Name & Address &nb= sp; = </= span>Job Title &nbs= p; &= nbsp; Supervisor &= nbsp; <u= >From To ______________________________________________________= ____________________________________ ______________________________________________________= ____________________________________ <o:p> </o:p> Have you ever= been convicted of anything other than minor traffic violations? &n= bsp; YES &= nbsp; NO<o:p></o:p> If yes, please explain: ________________________________________________________________________ ______________________________________________________= ___________________________________ <o:p> </o:p> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi= dth=3D651 style=3D'width:488.4pt;border-collapse:collapse;border:none;mso-border-alt= :solid windowtext .5pt; mso-padding-alt:0in 5.4pt 0in 5.4pt;mso-border-insideh:.5pt solid windowte= xt; mso-border-insidev:.5pt solid windowtext'> <tr style=3D'height:.25in'> <td width=3D651 colspan=3D3 style=3D'width:488.4pt;border:solid windowtex= t 1.0pt; mso-border-alt:solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.= 25in'> I fully underst= and that, if accepted into either the Senior Companion or Foster Grandparent Program, I am a volunteer in the program and not an employee of <st1:Plac= eName w:st=3D"on">Northern</st1:PlaceName> <st1:PlaceName w:st=3D"on">Arizona</= st1:PlaceName> <st1:PlaceType w:st=3D"on">University</st1:PlaceType> or the State of <st= 1:State w:st=3D"on"><st1:place w:st=3D"on">Arizona</st1:place></st1:State>. Also, as a volunteer, I realize = that I receive a tax-free stipend and not a taxable wage for my volunteer effort= s. If I drive, I certify that I am covered and will maintain the <st1:place w:st=3D"on"><st1:PlaceName w:st= =3D"on">Arizona</st1:PlaceName> <st1:PlaceType w:st=3D"on">State</st1:PlaceType></st1:place> minimum automobile liability insurance.<o:p>= </o:p> </td> </tr> <tr style=3D'height:.25in'> <td width=3D651 colspan=3D3 style=3D'width:488.4pt;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt;height:.25in'> I hereby certif= y that under penalty of perjury that the answers given above is true and correct= to the best of my knowledge and belief and agree to have a background check completed. <o:p></o:p> </td> </tr> <tr style=3D'height:.25in'> <td width=3D651 colspan=3D3 style=3D'width:488.4pt;border:solid windowtex= t 1.0pt; border-top:none;mso-border-top-alt:solid windowtext .5pt;mso-border-alt:s= olid windowtext .5pt; padding:0in 5.4pt 0in 5.4pt;height:.25in'> Applicant Certification, un= der penalties of perjury, I certify that:<o:p></o:p> <![if !supportLists]>a. </s= pan><![endif]>The number shown on this form is my correct taxpayer identification number (social security number).<o:p></o:p></span= > <![if !supportLists]>b. &nbs= p; <![endif]>I am not subject to backup withholding.<o:p></o= :p> <![if !supportLists]>c. &nbs= p; <![endif]>I am a person residing in the <st1:country-regi= on w:st=3D"on"><st1:place w:st=3D"on">u.s.</st1:place></st1:country-region><= o:p></o:p> </td> </tr> <tr style=3D'mso-yfti-lastrow:yes;height:.4in'> <td width=3D161 valign=3Dbottom style=3D'width:120.85pt;border:none;mso-b= order-top-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.4in'> Signature: <o:p></o:p></spa= n> <o:p> </o:p> ___________________________= __________________________________<o= :p></o:p> </td> <td width=3D161 valign=3Dbottom style=3D'width:120.9pt;border:none;mso-bo= rder-top-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.4in'> <o:p> </o:p> </td> <td width=3D329 valign=3Dtop style=3D'width:246.65pt;border:none;mso-bord= er-top-alt: solid windowtext .5pt;padding:0in 5.4pt 0in 5.4pt;height:.4in'> Date: <o:p></o:p> <o:p> </o:p> ___________________________= _________________<o:p></o:p> </td> </tr> </table> I have viewed an official p= icture Identification Card for the person listed on this application. The Picture ID Card I viewe= d was a ____Driver’s Lice= nse &= nbsp; _____State of AZ Picture ID &nb= sp; _____Passport ID </span= >____Other—please identify:_______________________________________= __________ <o:p> </o:p> Volunteer Coordinator Signa= ture:________________________________________Date:________= __________ <o:p> </o:p> <o:p> </o:p> FOR OFFICE USE ONLY: &= nbsp; ENROLLMENT DATE: ______________________ &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; VOLUNTEER STATION: ____________________ TRAINING COMPLETED: ___________________ <![if !vml]> <table cellpadding=3D0 cellspacing=3D0> <tr> <td width=3D682 height=3D141 style=3D'vertical-align:top'><![endif]><![if= !mso]> <table cellpadding=3D0 cellspacing=3D0 width=3D"100%"> <tr> <td><![endif]> <div v:shape=3D"_x0000_s1029" style=3D'padding:0pt 0pt 0pt 0pt' class= =3Dshape> <div style=3D'mso-element:para-border-div;border:solid white 1.0pt; mso-border-alt:solid white .75pt;padding:0in 0in 0in 0in'> <![if !vml]><img width=3D678 height=3D137 src=3D"ApplicationFormSCP-FGPwebpage_files/image004.gif" v:shapes=3D"_x= 0000_i1025"><![endif]> </div> </div> <![if !mso]></td> </tr> </table> <![endif]><![if !mso & !vml]> <![endif]><![if !vml]></td> </tr> </table> <![endif]>DIRECTOR SIGNATURE: ___________________ &= nbsp; &= nbsp; 1 &= nbsp; 2 &= nbsp; 3 &= nbsp; 4 &= nbsp; 5 <o:p> </o:p> <h2 align=3Dleft style=3D'text-align:left'><o:p> </o:p></h2> <h2>RELEASE AND AUTHORIZATION</h2> <o:p> </o:p> <o:p> </o:p> In connection with this req= uest, I authorize all corporations, companies, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts, military services and persons to release information they m= ay have about me to the person or company with which this form has been filed,= or their agent, Fidelifacts, 3030 N. Central Ave., Ste. 502, Phoenix, Arizona = and releases all parties involved from any liability and responsibility for doi= ng so. <o:p> </o:p> I also authorize the procur= ement of an investigative consumer report and understand that it may contain informa= tion about my backgrounds, mode of living, character, and personal reputation.<s= pan style=3D'mso-spacerun:yes'> This authorization, in original or= copy form, shall be valid for this and any future reports or updates that maybe requested. Further informatio= n may be available upon written request within a reasonable period of time. <o:p> </o:p> I authorize the <st1:PlaceN= ame w:st=3D"on">National</st1:PlaceName> <st1:PlaceName w:st=3D"on">Personnel</= st1:PlaceName> <st1:PlaceName w:st=3D"on">Records</st1:PlaceName> <st1:PlaceType w:st=3D"o= n">Center</st1:PlaceType>, <st1:place w:st=3D"on"><st1:City w:st=3D"on">St. Louis</st1:City>, <st1:Sta= te w:st=3D"on">Missouri</st1:State></st1:place> or other custodian of my mili= tary records to release to Fidelifacts/Phoenix information or photocopies of my military records, or only the following information/records: ____________________________________________________________________= ____ ___________________________= ______________________________________________________________ <o:p> </o:p> Service #: __________________________________ Branch of Service: __________________ <o:p> </o:p> From: _______________To: __________________ <o:p> </o:p> <o:p> </o:p> <o:p> </o:p> ___________________________= ___________________________________________________ APPLICANT’S SIGNATURE= &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; </s= pan>DATE <o:p> </o:p> </div> </body> </html> ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image001.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODdhkAIEAHcAACH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACwAAAAAkAIEAIAAAAAB AgMCNISPqcvtD6OctNqLs968+w+G4kiW5omm6sq27gvH8kzX9o3n+s73/g8MCofEovGITCqXyAIA Ow== ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image002.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODdhcAIEAHcAACH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACwAAAAAcAIEAIAAAAAB AgMCM4SPqcvtD6OctNqLs968+w+G4kiW5omm6sq27gvH8kzX9o3n+s73/g8MCofEovGITCofBQA7 ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image003.wmz Content-Transfer-Encoding: base64 Content-Type: image/x-wmz H4sIAAAAAAACC7t+9tgsBoY3/+N+ZsuIMOxmYQCCdE9GBk4GBuYQIJuJQQIkxMAKxNxMcT/f/Aex eJi2sdXLgBSzMYLVMvxiYgWr+///P4MSA0hGl5EBKsPGwMMAATAZRrCpqsxcDKoMt/9D8PSfIGwk A8O3/4MwTB5mIoj+ANTPzAADAPyY8BjCAAAA ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/image004.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhpgKJAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAgABgCY AoAAgAAAAAAAAAL/jI+py+0Po5y02ouz3rz7D4biSJbmeQLqyrbuC8fyTNf2jef6zvf+DwwKh8Si 8YhMKpdIA/MJjUqn1Kr1is1qt9ycswsOi8fksvmMTl+/6rb7DY/L53Q4u47P6/f8vr999yc4SFho eGgYiLjI2Oj4CKmkGElZaXmJWTiZydnp+QmKtRlKWmp6ihozmsra6vrKuAo7S1trqyZ7q7vL28uU 6xssPEwsA1yMnKxce7zs/Azt2RxNXW19OH2tvc0tl90NHi7e9T1ufo4uGZDO3u7+u/4uP0+/U16P nz9+r9/vX83vn8CBxQISPIjwlsGEDBumWugwosROECdavPioIsaN/xwHaewIMmSdjyJLmkxD8qTK leTisXwJc07KmDRrNnFpM6dOLjN3+vxZoyfQoURXCC2K1OfRpExrLm0KleXTqFRLTq2KlePVrFwn bu0KluHXsGQHji2LVt/ZtGznrW0Ll93buHT34ayLt+PcvHyt7e0L+NnfwISRDS6MONjhxIx1LW4M edbjyJRZTa6MudTlzJyl3e0Mmtvm0KQjjS6NOtbn1KyTnW4N+8/r2LT1zK6NW+bq3Lxh3e4NHM3v 4MTHDC+OnOfu5MwzHW8Ofcrz6NThVb9eaTr27UO0c//uwzv48V6Wkz9PRzz69TDUs39v1Dz8+WXc 019v//75/PrH867v/91/AG4n4IDXFWggdQgmCN2CDDLn4IPIRSghcRRWCNyFGPKm4Ya4deghbSCG CNuIJLJm4omopagiaSy2CNqLMHIm44yY1WgjZTjmCNmOPDLm44+IBSkkYUQWCdiRSPKl5JJ4Nekk XVBGCdeUVLJl5ZVoZaklWVx2CdaXYHIl5phYlWkmVWimCdWabDLl5ptIxSknUXTWCRQKeu7JZ59+ /glooIIOSmihhh6KQQEAOw== ------=_NextPart_01C73A22.2EF2ED80 Content-Location: file:///C:/06899145/ApplicationFormSCP-FGPwebpage_files/filelist.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" <xml xmlns:o=3D"urn:schemas-microsoft-com:office:office"> <o:MainFile HRef=3D"../ApplicationFormSCP-FGPwebpage.htm"/> <o:File HRef=3D"image001.gif"/> <o:File HRef=3D"image002.gif"/> <o:File HRef=3D"image003.wmz"/> <o:File HRef=3D"image004.gif"/> <o:File HRef=3D"filelist.xml"/> </xml> ------=_NextPart_01C73A22.2EF2ED80--