Enclosure (3) to COMDINST 1750.4D
V O LU N T EER A G REEM EN T FO R
A PPRO PRIA T ED FU N D A CTIV IT IES
N O N A PPROPRIA TED FUN D INS T R U M EN T A LIT IES
PRIV A CY A CT S TA T EM EN T
A U T H ORIT Y: Sec t ion 1 5 8 8 of T it le 1 0, U. S. C ode, and E. O. 9 39 7 .
PRIN C IPA L PU RPOSE(S): T o doc um ent v olunt ary serv ices prov ided by an indiv idual, inc luding t he hours of serv ic e perf orm ed, and t o
obt ain agreem ent f rom t he v olunt eer on t he c onditions f or ac c ept ing t he perf orm anc e of v olunt ary serv ic e.
ROU T IN E U SE(S): N one.
D ISC LOSU RE: V olunt ary ; how ev er f ailure t o c om plete t he f orm m ay result in an inabilit y t o ac c ept v olunt ary serv ic es or an inabilit y t o
doc um ent t he t y pe of v olunt ary serv ic es and hours perf orm ed.
PA RT I - GEN ERA L INFO RM A T ION
1 . T YPED N AM E OF V OLUN T EER (Las t, Firs t, M iddle Initial)
2 . SSN
3 . DA T E OF BIRT H (YYYY M M D D )
4 . IN STA LLAT ION
5 . ORGA N IZ A T ION / UN IT W H ERE SERV ICE OCC U RS
6 . PROGRA M W H ERE SERVIC E OC C U RS
7 . A N T IC IPA TED D AYS OF W EEK
8 . A NT IC IPA T ED H OU RS
9 . D ESC RIPT ION OF V OLU N TEER SERV IC ES
PA RT II - V OLU N T EER IN A PPROPRIA T ED FU N D A CT IV IT IES
1 0 . C ERT IFICA T ION
I ex pressly agree that my serv ic es are being provided as a v olunt eer and that I w ill not be an em ploy ee of t he U nit ed St at es
Gov ernm ent or any inst rum ent alit y t hereof , exc ept f or c ert ain purposes relat ing t o c om pensat ion f or injuries oc c urring during t he
perf orm ance of approv ed v olunt eer serv ices, t ort c laim s, the Priv ac y Ac t , c rim inal c onf lic t s of int erest , and def ense of c ert ain suit s arising
out of legal m alprac t ic e. I ex pressly agree t hat I am neit her ent it led t o nor ex pec t any present or f ut ure salary , w ages, or ot her benef it s
f or t hese v olunt ary serv ic es. I agree t o be bound by the law s and regulat ions applicable to v olunt ary serv ice providers and agree t o
part ic ipat e in any t raining required by t he installation or unit in order f or m e t o perform the v olunt ary serv ic es t hat I am of fering. I agree
t o f ollow all rules and proc edures of t he inst allat ion or unit t hat apply t o the v olunt ary serv ic es I w ill be providing.
a. SIGN A T U RE OF V OLU N T EER
b. D A T E SIGN ED (YYYY M M D D )
1 1 .a. T YPED N A M E O F A C C EPT IN G OFFIC IA L
b. SIGN A T U RE
c. D A T E SIGN ED (YYYY M M D D )
(Las t, Firs t, M iddle Initial)
PA RT III - V OLU N T EER IN N ONA PPROPRIA T ED FU N D IN ST RU M EN TA LIT IES
1 2 . C ERT IFICA T ION
I ex pressly agree that my serv ic es are being provided as a v olunt eer and that I w ill not be an em ploy ee of t he U nit ed St at es
Gov ernm ent or any inst rum ent alit y t hereof , exc ept f or c ert ain purposes relat ing t o c om pensat ion f or injuries oc c urring during t he
perf orm anc e of approv ed v olunt eer serv ic es and liabilit y f or t ort c laim s as spec if ied in 1 0 U. S. C. Sec t ion 1 58 8 (d)(2 ). I ex pre ssly agree
t hat I am neither ent it led t o nor ex pec t any present or f ut ure salary , w ages, or ot her benefit s f or t hese v olunt ary serv ices. I agree t o be
bound by t he law s and regulat ions applic able t o volunt ary serv ic e prov iders, and agree t o part ic ipat e in any t raining required by t he
inst allat ion or unit in order for m e t o perf orm t he v olunt ary servic es t hat I am of f ering. I agree to f ollow all rules and proc edures of t he
inst allat ion or unit t hat apply t o the v olunt ary serv ic es that I am of fering.
a. SIGN A T U RE OF V OLU N T EER
b. D A T E SIGN ED (YYYY M M D D )
1 3 .a. T YPED N A M E O F A C C EPT IN G OFFIC IA L
b. SIGN A T U RE
c. D A T E SIGN ED (YYYY M M D D )
(La s t, Firs t, M i ddle Initial)
PA RT IV - T O BE COM PLETED A T EN D OF V OLU N T EER' S S ERV ICE BY V OLU N TEER S U PERV IS OR
1 5 . SIGN AT U RE
1 6 . TERM INA T ION D A T E
1 4 . A M OU N T OF V OLU N T EER T IM E D ON A T ED
(Y YYYM M D D )
a. YEA RS (2 ,0 8 7
b. W EEKS
c. D A YS
d. H O U RS
hours = 1 y ear)
1 7 .a. T YPED N A M E O F SU PERV ISOR
b. SIGN A T U RE
c. D A T E SIGN ED (YYYY M M D D )
(Las t, Firs t, M iddle Initial)
D D FO RM 2 7 9 3 , FEB 2 0 0 2
Excep t io n t o St an d ard Fo rm 5 0 g ran t ed b y
PREV IOU S EDIT ION IS OBSOLET E.
Of f ice o f Perso n n el M an ag em en t (OPM ) w aiver.
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