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KINGSWAY CHARITIES INC. INTERNATIONAL 1119 Commonwealth Ave. Bristol VA. 24201 Toll Free Phone: 800-321-9234 Phone: 276-466-3014

NEW VOLUNTEER APPLICATION FORM

PLEASE COMPLETE ALL REQUIRED INFORMATION ( * ): Volunteer Name: *    First:      Last: Volunteer's Spouse Name:    First:      Last: Volunteer Address 1: *    Volunteer Address 2:    Volunteer City: *    Volunteer State: *    Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Volunteer Zip/Postal Code *    Volunteer E-Mail: *    Volunteer Phone: *    Volunteer Cell:    Volunteer Birth Date:    Please include t-shirt size:           Where do you attend church?           If you have any health restrictions, please list?           Have you ever been convicted of a misdemeanor or felony for substance abuse?    Yes  No    Have you ever done volunteer work?    Yes  No     What kind?    The choices of volunteer work available are:    Sort Donations Intake Pick/Pack Orders Pallet Jack Fork Lift Computer Entry Other skills and interests:    What days would be most convenient for you?   * Monday Tuesday Wenesday Thursday Friday What times would be most convenient for you?   * Morning Afternoon Are you available on short notice?    Yes  No     Person to contact in case of emergency:   *        Additional information, work experience if you want to use it, etc:    Please check the information you entered and make sure everything is correct. Click Submit just one time when you are finished and wait for the confirmation screen to load. Thanks.

Any Questions or Issues Contact Us at the Address/Phone Below Kingsway Charities, Inc International Medical Missions 1119 Commonwealth Ave. Bristol, Va 24201 (800)321-9234    (276)466-3014