Street Address: ____________________________________________________________

City: _________________________________ State: __________ Zip Code: ___________

Home Telephone: __________________ Email Address: ____________________________

Are you at least 16 years old? ___ yes ___ no

In Case of Emergency contact:

a. Name _______________________________________ Telephone _________________

b. Name _______________________________________ Telephone _________________

If emergency contacts cannot be reached, the Library Shop on Main reserves the right to seek
medical assistance at the nearest medical facility and will be held harmless in all legal issues
which may arise from this decision.

If you have a disability, what reasonable accommodations would you need to perform

this volunteer position? ____________________________________________________

________________________________________________________________________

Have you volunteered for other organizations? If yes, when, where and in what capacity

was it performed? _________________________________________________________

________________________________________________________________________

________________________________________________________________________

To assist us in filling our needs, please list any skills, hobbies, special training, areas of

expertise that you may have. _________________________________________________

_________________________________________________________________________

_________________________________________________________________________

What days and time would you prefer to volunteer?

Monday-Thursday: ___10 am - 1 pm; ___12 - 4 pm; ___3 - 6 pm;

Friday & Saturday: ___10 am - 1 pm; ___12 - 4 pm

Sunday: ___1 - 4 pm

List the names of three people, not related to you, who can give you a reference:

a. Name: _______________________________Telephone: __________________________

b. Name: _______________________________Telephone: __________________________

c. Name: _______________________________Telephone: __________________________

I authorize the Library Shop on Main to make inquiry into statements made by me on this application and
relevant information in the volunteer consideration process. I acknowledge and agree that any falsification,
misrepresentation or omission of facts will, at this agency’s option, result in making this application null and
void, and will, if I become associated with the organization on a voluntary basis, result in termination of my
voluntary association. I understand that completion of this application does not indicate whether there are any
positions currently open and that it does not obligate the agency to extend association on a voluntary basis.
This certifies that information given on this application is true and complete to the best of my knowledge.

Signature: ___________________________________________Date: ________________

The Library Shop on Main is a voluntary organization operated by the Friends of Main Library that complies
fully with all State and Federal laws prohibiting discrimination because of age, sex, pregnancy, sexual harassment,
race, color, religion, national origin, marital status, physical disability, sexual orientation, veteran status and laws
pertaining to eligibility to work in the United States.

Please return the completed application to:
LSOM Shop Coordinator, 60 S. High St., Akron, Ohio 44326
or fax this form to: 330-643-9094

This page last updated 7/15/2009