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Volunteer APPLICATION

Support incarcerated Muslims through faith and service. Volunteer your time, skills, or heart and make a real difference.

Personal Information

Last Name *

First Name *

Mailing Address *

City *

State *

Zip Code *

Cell Phone Number *

Home Phone Number (Optional)

Alternate Phone Number (Optional)

Do you have a valid driver’s license? *

Yes

Issuing State

Do you have any restrictions on driving? *

Yes

Have you ever been convicted of a felony? *

Yes

Have you ever been convicted of a misdemeanor that might reasonably affect your ability to perform this job? *

Yes

If you were in prison, what date were you released?

If yes, what is the end date of your probation?

Are you on probation? *

Yes

Education

Name and Location *

High School

Undergraduate

Graduate

Other

Name and Address

Year Graduated

Type of Degree or Certificate

Major/Minor Field of Study

Please list Certifications, Licenses, etc., and provide their copies, that are applicable to this position *

Muslim Chaplain/Imam Experience

Can you lead congregational prayers? *

Yes

Can you deliver Friday Sermon? *

Yes

Can you deliver Eid sermon? *

Yes

Can you conduct & lead Islamic study class? *

Yes

Can you teach Arabic to non-Arabic speaking? *

Yes

Years experience

Comments, if any

Skills

Fluency in English

Read

Write

Speak

Please check all that apply

Fluency in Arabic

Read

Write

Speak

Please check all that apply

List below any other languages you know (specify if you can Read, Write, and Speak)

Please list any other skills that you have, which may be applicable to this position (Conflict resolution, counseling, teaching, mentoring, training, mentoring, etc.) *

List your computer skills

Employment and related experience

List present or last employer first

Job Title *

Employer Name and Address *

From *

To *

Job Status *

Full-time

Part-time

If Part-time put # of hours/week

Description of Duties *

Reason for Leaving *

(If currently employed, indicate reason you desire to leave)

Employer can be contacted for reference? *

Yes

If additional space is needed to list jobs held, please write them on a piece of paper and attach to the application.

Please write below how you can contribute to the MCSVA? *

Certification of Application Information

I certify that the information I have provided in this application is true and correct, and that no attempt has been made to conceal pertinent information. I understand that if any information given by me is found to be false or misleading, I may be subject to dismissal at any time, and I agree to hold The MCSVA, its officials, and employees harmless in that event. I further authorize The MCSVA to conduct a background investigation in connection with my application for employment, which may include information related to my credit, educational background, criminal history, motor vehicle records, current and past employers, professional and personal references, military records, and any other relevant sources. I authorize the release of any such information to The MCSVA, understanding that all information obtained will be used solely in accordance with applicable laws.

Drug Testing/Background Checks Information

In accordance with the Federal Drug Free Workplace Act and applicable Commonwealth of Virginia laws, the MCSVA will require all applicants to undergo pre-employment drug testing and background checks. I understand that should I fail the drug test or the background check, I will be excluded from job opportunities with MCSVA.

Signature *

Clear

Date *