Enclosure (3) to COMDINST 1750.4D
U.S. DEPARTMENT OF
DATE:
APPLICATION TO VOLUNTEER AS A COAST
HOMELAND SECURITY
GUARD OMBUDSMAN
U.S. COAST GUARD
For use of this form, see Ombudsman Program, COMDTINST
CG- 6078 (3-06)
1750.4 (series); the proponent agency is CG-1112
PRIVACY ACT STATEMENT
AUTHORITY: Section 1588 of Title 10, U.S. Code, and E.O. 9397.
PRINCIPLE PURPOSE(S): to document voluntary services provided by an individual, including the hours of service performed, and to obtain agreement from the volunteer on the conditions
for accepting the performance of voluntary service.
ROUTINE USERS(S): None.
DISCLOSURE: Voluntary; however failure to complete the form may result in an inability to accept voluntary services or an inability to document the type of voluntary services and hours
performed.
GENERAL INFORMATION
1. NAME OF VOLUNTEER (Last, First, Middle Initial ):
2. SOCIAL SECURITY NUMBER:
3. PHONE NUMBER:
4. DATE OF BIRTH:
5. NAME OF SPOUSE: (Last, First, Middle Initial)
6. SOCIAL SECURITY NUMBER:
7. MAILING ADDRESS:
8. EMERGENCY CONTACT NAME:(Last, First, Middle Initial)
9. EMERGENCY CONTACT PHONE NUMBER:
10. IF EMPLOYED, EMPLOYER NAME AND ADDRESS:
11. YOUR POSITION:
BACKGROUND INFORMATION
2. ISSUING STATE:
1. DO YOU HAVE A VALID DRIVER'S LICENSE?
NO
YES
3. LICENSE NUMBER:
4. EXP. DATE (DD/MM/YYYY):
5. WITH THE EXCEPTION OF MINOR TRAFFIC VIOLATIONS, HAVE YOU EVER BEEN CONVICTED OF, OR ARE
YOU
CURRENTLY CHARGED WITH ANY MISDEMEANORS OR FELONIES? (IF YES, PLEASE EXPLAIN ON
THE BACK OF THIS PAGE.)
YES
NO
6. ANY PRIOR SUBSTANTIATED FAMILY ADVOCACY INVOLVEMENT?
YES
NO
7. DO YOU GIVE PERMISSION FOR THE COAST GUARD TO DO A FAMILY ADVOCACY REFERENCE CHECK?
YES
NO
SIGNATURE OF VOLUNTEER:
DATE:
DO NOT WRITE IN THIS SPACE FOR FAMILY ADVOCACY SPECIALIST COMMENT ONLY:
FAS SIGNATURE:
CONTACT FOR ADDITIONAL GUIDANCE
YES
NO
DATE:
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