Meals on Wheels Volunteer Application

2. 65 Mount Hope Road Rockaway, NJ 07866

   65 Mount Hope Road Rockaway, NJ 07866

4. Department of Community Services

   Joseph S. Fiorilla, Director

   Joseph S. Fiorilla, Director

6. Peter N. Tabbot, Health Officer / R.E.H.S

   Peter N. Tabbot, Health Officer / R.E.H.S

8. Volunteer Resume / Application

10. Last Name

11. First Name

12. Middle Initial

14. Street Address

16. City

17. State

18. Zip

20. Home Phone

21. Cell / Pager Number

23. Email

25. Current Employer

27. Street Address

29. City

30. State

31. Zip

33. Emergency Contact:

34. Emergency Contact Phone Number

38. Please indicate the Route you would like to deliver:

    1. Route A; Mt. Hope and White Meadow Lake
    2. Route B; Hibernia, Lake Telemark and Green Pond
    3. Either Route

    Meals on Wheels delivers hot meals to individuals along two routes in Rockaway Township. Please note these are general areas, and may change.

42. New Jersey Driver's License Number

43. Expiration Date
    Expiration Date

45. Have you ever been convicted of a crime other than a minor traffic violation?

    1. No
    2. Yes

46. Have you ever been convicted of driving under the influence?

    1. No
    2. Yes

47. Are you currently required to register with a law enforcement agency under Megan’s Law?

    1. No
    2. Yes

49. If yes to any of the above, state what the conviction was for, the town and the state where the conviction was made and the date.

51. Additional Personal References We May Contact:

53. Name

54. Relationship

55. Phone

57. Name

58. Relationship

59. Phone

61. Name

62. Relationship

63. Phone

65. Signature*

    I certify that the information provided by me is true and accurate to the best of my knowledge. I understand that if any such information is willfully false, I am subject punishment. I further understand that falsification of this application and content herein may result in dismissal as a volunteer from Rockaway Township programs. I authorize Rockaway Township to investigate all statements contained in this application. I acknowledge that if I drive my own vehicle on behalf of Rockaway Township, I will always maintain in force adequate automobile insurance; and I also understand that as a volunteer driver, the limits and coverages provided by my personal automobile insurance are applicable to any accidents or incidents that involve my vehicle, including those that occur while I am serving as a volunteer driver for Rockaway Township.

    1. I Agree
66. Date
    Date

68. Date Application Was Received
    Date Application Was Received

    Date Application Was Received

69. Copy of New Jersey Driver's License

    1. Yes
    2. No

Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit Submit and Print

* indicates a required field