Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Mobile Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Emergency contact *

First Name

Last Name

Emergency contact phone *

(###)

###

####

What are your areas of interest? (Check all that apply) *

Visitor services (greeter, docent/tour guide, lecturer, visitors center)

Marketing & Communications (newsletter, social media, news releases, website updates)

Events management (facility rentals, managing events, mill demonstration days)

Education (children's tours, educational programs, developing activities)

Collections (documenting artifacts, collections data base)

Maintenance (groundskeeping, simple repairs)

Reference #1: Name *

First Name

Last Name

Reference #1: Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference #1: Phone *

(###)

###

####

Reference #2: Name *

First Name

Last Name

Reference #2: Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reference #2: Phone *

(###)

###

####

Are you willing to submit to a Pennsylvania Background Check per Pennsylvania Child Abuse History Clearance? *

Yes

No

Date *

MM

DD

YYYY