VOLUNTEER APPLICATION AND BACKGROUND CHECK AUTHORIZATION FORM

Organization/Group Affiliation:

Last Name:

First Name:

Middle Name:

List any aliases and/or other legal names:

Date of Birth (Format mm/dd/yyyy):

Gender:

Male

Female

Home Address (Street):

City:

State:

ZIP/Postal Code

Email Address:

Are you currently employed by Michigan State University:

Yes

Have you ever been employed by Michigan State University:

Yes

If yes, please provide Department name and reason for termination:

Emergency Contact Name

Home Phone:

Cell Phone or Local Phone Number: