Fill and Sign the Andrew L Hutchins Memorial Scholarship Application Jmg Form

NJ DEP Division of Fish and Wildlife APPLICATION FOR THE WILDLIFE CONSERVATION CORPS Please print out and mail to the address on page 5 1. GENERAL INFORMATION: (Please print clearly) Name: _____________________________________________________________________ Address: ___________________________________________________________________ City, State, Zip: ______________________________________________________________ County of Residence: _________________________________________________________ Date of Birth: ________________________________________________________________ Home Phone No: ____________________ Daytime/Cell Phone No: ____________________ **E-mail Address: ____________________________________________________________ MUST BE SUPPLIED **All volunteer notifications are made by email so please include one as this is the only way you will be notified about volunteer opportunities. 2. BACKGROUND DATA: Completion of this part is optional and is to be used only for complying with EEOC Guidelines and the New Jersey State Affirmative Action Program. Check the group you are a member of: White (Non-Hispanic) Black (Non-Hispanic) Asian or Pacific Islander (including Indian Subcontinent) American Indian or Alaskan Native Hispanic What days are you available? (Please Circle) Sunday Monday Tuesday Wednesday Thursday Friday Saturday For how many hours per year are you willing to commit to the WCC program? (Please Circle) 40 hrs. 60 hrs. 80 hrs. More than 80 hrs. Other: _____________________ Driver’s License – State & No.: __________________________________________________ 1 Describe other job experiences, past & present: DATE EMPLOYER JOB DESCRIPTION ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Please describe other volunteer experience you have had: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 3. AREAS OF INTEREST: (please mark “X” on only those you wish to receive information/job opportunities). ______Bureau of Freshwater Fisheries ______Bureau of Marine Fisheries Examples of work: Fish surveys, research, fish propagation. Examples of work: Ocean trawl surveys, research. ______Office of Information & Education Examples of work: Fishing education, hunter/fishing mentor programs, outreach programs, interpretive tour guide. ______Bureau of Land Management Examples of work: Fish stocking, pheasant stocking, range cleanup, wildlife management area habitat projects. ______Bureau of Wildlife Management Examples of work: Deer Project, Bear Project, upland game, furbearer, waterfowl. ______Bureau of Shellfisheries Examples of work: Research projects ______Endangered & Nongame Species Program Examples of work: Research, vernal pool surveys, amphibian surveys, eagle surveys, Speakers Bureau. _____Wildlife Permits Unit Examples of work: Exotic, Nongame and Captive Game permittee inspection assistance, mailings, office duties. ______Office Work Examples of work: Data entry, filing, photo copying. 2 Skills you possess: (Please check all that apply) Firearms Instructor – list certification ________________________________________ Computer Construction Photography Data Entry Typing/Clerical Boating Experience Degree – Wildlife Management Degree – Fisheries Management Law Enforcement Art/Design Engineering Writing Other Degrees: _________________________________________________________ Publishing Other:_________________________________________________________________ CDL License / Boat Captain License? If Yes, what type: ________________________ Have you ever been convicted of a Fish & Wildlife Violation? (Please Circle) YES NO If yes, please explain: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Please indicate if reasonable accommodations are needed to perform the assigned duties and functions as a volunteer. Disclosure of this information will not disqualify you from volunteer service. If reasonable accommodation is required, please describe the type of accommodation. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 4. REFERENCES: List a reference (not a relative) that we may contact to verify your qualifications: ___________________________________________________________________________ Name Address Phone 3 PLEASE IDENTIFY ANY PHYSICAL OR MEDICAL CONDITION (INCLUDING ALLERGIES AND MEDICATION YOU ARE TAKING) WHICH MIGHT AFFECT YOUR PERFORMANCE OR WHICH SHOULD BE BROUGHT TO THE ATTENTION OF THE DIVISION OF FISH & WILDLIFE TO ENABLE THEM TO TREAT YOU IN AN EMERGENCY SITUATION. DISCLOSURE OF THIS INFORMATION WILL NOT DISQUALIFY YOU FROM VOLUNTEER SERVICE. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Name of person to contact in Case of Emergency: Name: ______________________________________________________________________ Home Phone: ________________________ Work Phone: ____________________________ Cell: ____________________________ Relation to you (spouse, parent, friend, etc.): _______________________________________ While I Volunteer, I… Understand the requirements of time and duties before accepting them Will consider the assignment a serious professional commitment and view the position as valid and important Will be aware of and abide by the policies and procedures of the NJ Division of Fish and Wildlife Will participate fully in any training and meetings associated with the volunteer projects I choose Will dress in an appropriate and professional manner for the position assigned Will follow the volunteer assignment and accept supervision Will return equipment at completion of assignment Will give accurate information to the public and respect confidentiality guidelines for protecting rare and endangered wildlife Will work towards the betterment of the NJ Division of Fish and Wildlife and not for personal gain I hereby affirm that I have read this application and agree to abide by all of the expectations of the Wildlife Conservation Corps and NJ Division of Fish & Wildlife. I hereby affirm that the information provided by me on this application is true to the best of my knowledge. I understand that any false representation by the applicant who knows or reasonably should know that the representation is false, and who has submitted the representation to induce the Department to take action, shall subject the applicant to removal from the WCC based upon false information. I have read these conditions and by signing and dating this application, I acknowledge and agree to all of the WCC requirements. NAME: _________________________________________________________________________ SIGNATURE________________________________________DATE _______________________ MUST BE SUPPLIED 4 MUST BE SUPPLIED ♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦ Please email a passport size digital photo of yourself (from the shoulders up) so a WCC Identification badge can be made for you (Please indicate that your application has been mailed). Photos can be emailed to WCC_DEP@dep.state.nj.us. If you do not have a digital photo of yourself, you can mail a passport size photo with your application. ♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦ When complete, mail to: NJ Division of Fish and Wildlife Wildlife Conservation Corps 26 Rt. 173 West Hampton, NJ 08827 908-735-7040 This program receives Federal financial assistance from the U.S. Fish and Wildlife Service. Under Title VI of the 1964 Civil Rights Act, Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, and title IX of the Education Amendments of 1972, the U.S. Department of the Interior prohibits discrimination on the basis of race, color, national origin, age, sex, or disability. If you believe that you have been discriminated against in any program, activity, or facility, or if you need more information please write to: Us Fish and Wildlife Service The Civil Rights Coordinator for Public Access 4401 N. Fairfax Drive Mail Stop: WSFR-4020 Arlington, Virginia 22203 5