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Step 1 of 6 16% Personal DataName First Last Physical Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone (primary)Phone (secondary)Email Enter Email Confirm Email Employment InformationPosition(s) applying for Dog kennel attendant Shelter front desk Shelter manager Other Type of employment desired Full-time Part-time Temporary Would you be willing to work overtime? Yes No Date you can begin work MM slash DD slash YYYY Salary/wage desired Social Security Number What general timeframes would you be available for work? (please check any that apply)Monday Morning Afternoon Evening Tuesday Morning Afternoon Evening Wednesday Morning Afternoon Evening Thursday Morning Afternoon Evening Friday Morning Afternoon Evening Saturday Morning Afternoon Evening Sunday Morning Afternoon Evening Education and TrainingHigh School Name High School Address Dates attended Graduate high school Yes No College Name College Address Dates attended Graduate college Yes No College degree or certificate obtained College major/minor or field of study 'Other' Education Name 'Other' Address Dates attended Graduate 'other' Yes No 'Other' degree or certificate obtained 'Other' major/minor or field of study Employment ExperienceCompany 1 Name Company 1 Address Dates employed May we contact your present employer to verify the above? Yes Do not contact now, contact at a later date (choose in next field) Date we can contact current employer MM slash DD slash YYYY Please list any experience you have had with pets, working for animal welfare, etc.List Add Remove Have you been convicted of a felony in the last 5 years? Yes No If yes, briefly describe the circumstances of your conviction; the date, nature, and place of offense; and disposition of the case.Accuracy Agreement(Required) I have read and certify that the information provided is accurateI understand and agree that the information that I have provided is accurate to the best of my knowledge and subject to verification by the Humane Society of Pagosa Springs. A material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employment or, if employed, termination. In consideration of my employment, I agree to abide by the rules and regulations of the Humane Society of Pagosa Springs. I understand that these rules and regulations, and any personnel manual, do not constitute a contract of employment. I understand that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Employer or myself. Although the Humane Society of Pagosa Springs makes every effort to accommodate individual preferences, business needs at times make the following conditions mandatory: overtime or a work schedule other than Monday thru Friday. Indemnification Agreement Consent(Required) I have read the Liability Release and Indemnification Agreement, understand and agree to its contents with full knowledge of its significance.This agreement is made between the Humane Society of Pagosa Springs (hereinafter “HSPS”) and you, as a non-paid volunteer (hereinafter ”Volunteer”). This Volunteer Indemnification Agreement results from Volunteer’s agreement to volunteer services by working on a non-paid basis with the animals at the Humane Society of Pagosa Springs. Volunteers authorize HSPS to use any pictures taken of them in our newsletter or any other publication. Volunteers acknowledges by signing below that there is a risk of personal injury or death to Volunteer due to working with HSPS animals, some of which are feral or aggressive, such as but not limited to bites, scratches, tears, trips, falls, infections, diseases, death, emotional distress, or other injuries which may result in financial losses to Volunteer. Volunteer and HSPS agree that HSPS is not liable for any effects, direct or indirect, such as but not limited to bites, scratches, tears, trips, falls, infections, disease, death, emotional harm, loss of income due to injuries, the uninsured cost of medical or psychological care due to injuries or other injuries to Volunteer that may result from volunteer working at theHumane Society of Pagosa Springs or with animals in the care of Humane Society of Pagosa Springs at any location. By clicking the consent box below, Volunteer acknowledges and assumes the risk associated with working with HSPS animals. Volunteer hereby agrees to indemnify HSPS and hold it fully harmless from any and all liability of any kind that may result from Volunteer working with HSPS animals. This Indemnification Agreement shall hold HSPS and any of its officers, directors, paid and nonpaid employees, other volunteers, agents, or representatives harmless and shall fully indemnify them from all claims, demands, obligations, actions, causes or action, damages, costs and expense which may result from Volunteer working with HSPS animals. BINDING EFFECT This agreement shall be binding upon Volunteer’s executors, administrators, personal representatives, heirs, successors and assigns. GOVERNING LAW This agreement shall be construed and interpreted in accordance with the laws of the State of Colorado. LEGAL CAPACITY By checking the box above, Volunteer represents that he/she has read this Indemnification Agreement, understands it, has the legal capacity to enter into it, and agrees to be bound by its terms.Untitled
