Fill and Sign the Australia General Form Affidavit

OMB No. 0596-0080 Expires 8/2010 Instructions: Mark “x” in the appropriate boxes. For other items, either print or type responses If extra space is needed use item 18. Volunteer Application For Natural Resources Agencies 1. Name (Last, First, Middle) 2. Age 5. Street Address (include apartment number, if any) 3. Telephone Number 4. Email Address 6. City, State, and Zip Code 7. Which general volunteer work categories are you most interested in? Soil/ Watershed Archeology Historical/Preservation Botany Pest/Disease Control Timber/Fire Prevention Campground Host Minerals/Geology Trail/Campground Maintenance Construction Maintenance Natural Resources Planning Tour Guide/Interpretation Computers Office/Clerical Visitor Information Conservation Education Other (Please specify) Range/Livestock Fish/Wildlife Research/Librarian 8. What qualifications/skills/experience/education do you have that you would like to use in your volunteer work? Sign Language Backpacking/Camping Heavy Equipment Operation Biology Horses – Care/Riding Supervision Boat Operation Landscaping/Reforestation Other Trade skills (Please specify) Carpentry Land Surveying Clerical/Office Machines Livestock/Ranching Computer Programming Map reading Teaching Drafting/Graphics Working with People Mountaineering Driver’s License Photography Writing/Editing First Aid Certificate Public Speaking Other (Please specify) Hand/Power Tools Research/Librarian 9. Based on boxes checked in items 6 and 7, what particular type of volunteer work would you like to do? (Please describe any specific qualifications, skills, experience, or education that apply.) 10. a. Have you volunteered before? Yes No b. If Yes, please briefly describe your volunteer experience. 11. Would you like to supervise other volunteers? Yes No 12. What are some of your objectives for working as a volunteer? (Optional) 13. Please specify any physical limitations that may influence your volunteer work activities: Optional Form 301 (Revised 6/2007) USDA-USDI 14a. Which months would you be available for volunteer work? January February March July August September April October 14b. How many hours per week would you be available for volunteer work? Hours: 14c. Which days per week would you be available for volunteer work? Monday Tuesday Wednesday Thursday Friday May November June December Saturday Sunday 15. Specify at least three states or specific locations within a state where you would like to do volunteer work. 16. Specify your lodging requirements: I will furnish my own lodging (such as tent; camper; own, relative’s, or friend’s place). I will require assistance in finding lodging. 17. If a volunteer assignment is not available at the location specified in item 15, do you want your application forwarded to another location or Federal agency seeking volunteers with your background/interest? Yes No (Please specify) 18. This is provided for more detailed responses. Please indicate the item numbers to which these responses apply: Burden Statement According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0080. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) and U.S. Department of the Interior prohibit discrimination in all programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA and USDI are equal opportunity providers and employers. Notice to Volunteer Volunteers are not considered to be Federal employees for any purposes other than tort claims and injury compensation. Volunteer service is not creditable for leave accrual or any other benefit. However, volunteer service is creditable work experience. Privacy Act Statement Collection and use is covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the USDA and USDI for the purposes of tort claims and injury compensation. Furnishing this data is voluntary, however, if this form is incomplete, enrollment in the program cannot proceed. 19. Signature (Sign in ink) 20. Date Optional Form 301 (Revised 6/2007)