General Membership Application - Concerned Black Men of Los Angeles

Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Why are you interested in volunteering?*
Is there a specific mentoring program in CBMLA you are interested in supporting?*
Have you ever worked or do you currently work for CBMLA?*
Have you ever received services from CBMLA?*
Do you have a valid driver’s license?*
Drivers License Number*
Do you have a car available for use while volunteering?*
Experience and Education
What is your educational/training background?*
What is your employment history?*
Have you had any previous experience as a volunteer? If so, with what organizations, and what kind of work did you do?*
Does your current employer have (check all that apply):
- Program for volunteering
- Donation matching program
- Grant preference to organizations where you volunteer

Authorization Documents
AUTHORIZATION AND AGREEMENT BY APPLICANT*
- I certify that the facts set for in this volunteer application are true and complete to the best of my knowledge. I understand that any false statement, omission or misrepresentation in my application or placement interview may result in the rejection of my application or discharge from the volunteer program.
- If required, I consent to having CBMLA complete a criminal background check prior to membership or volunteering.
- If required, I agree to complete a drug screening and TB screening requirements relevant to the position for which I am applying
Concerned Black Men of Los Angeles considers applicants for membership/volunteering without regard to sex, race, age, religion, national origin, veteran or marital status, or any other legally protected status. We provide reasonable accommodation to qualified individuals with disabilities when it would not be an undue hardship. If you need a reasonable accommodation in the pre-placement process, please contact the President or Executive Director.
Name*
First Last Date
*Writing your name in the above field affirms that you agree with the aforementioned statements.
While the vast majority of members/volunteers are not involved with alcohol abuse or illegal drugs, those who are can have an adverse impact on the workplace, as well as their own job performance. To meet our obligations, and to comply with our obligation under the Drug Free Workplace Act of 1988, the following policy has been adopted and will be enforced:*
- The organization prohibits the unlawful use, sale, possession, manufacture, distribution, or being under the influence of alcohol, drugs or any controlled substance, on organization property, in the presence of organization clients, while on duty, during rest periods and break periods, while operating an organization vehicle or attending an organization-sponsored event.
- Members/Volunteers who violate this prohibition will be subject to disciplinary action, up to and including termination. Nothing in this policy restricts the organization’s right to terminate a member/volunteer at any time, with or without notice, for any reason not expressly prohibited by law.
- The organization retains the right to require any members/volunteer to report for drug and/or alcohol testing for reasonable suspicion or following an accident in which there is injury to persons or damage to property.
- Members/volunteers must abide by the terms of this statement and must notify the employer of any criminal drug conviction within five days of the conviction if workplace conduct is involved.
- New members/volunteers will be required to report for drug testing after a placement offer has been made but before reporting for the assignment.
Name*
First Last Date
I have read and understand the Drug Free Workplace Compliance Statement. I agree to comply with the CBMLA Drug and Alcohol Policy. I understand that any offer of placement with the Organization may be contingent upon the successful completion of drug testing before beginning assignment, and I consent to testing according to CBMLA policy.

References
Name of Reference #1*
First Last Relationship
Phone*
Email*
Name of Reference #2*
First Last Relationship
Phone*
Email*
Name of Reference #3*
First Last Relationship
Phone*
Email*

Concerned Black Men of Los Angeles Membership Application

Step 1 of 4

Experience and Education

Your Interest at CBMLA

Criminal History

Authorization Documents

References