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National Capital Volunteer Application












NOTE: Before answering this question regarding criminal convictions please refer to the instructions below if you reside or are applying for a position in Alaska, California, Connecticut, District of Columbia, Georgia, Hawaii, Massachusetts, Ohio or Washington.

A “yes” is not an automatic bar to volunteer service with the Susan G. Komen; the circumstances relating to the offense will be considered in relation to the volunteer position for which you are applying.


Alaska Applicants: Do not identify convictions that are more than ten (10) years old.

California Applicants: Do not identify convictions under California Health & Safety Code §§11357(b) or (c), 11360(b) (formerly subdivision (c) of section 11360), 11364, 11365, or 11550 related to marijuana offenses that occurred two or more years before the instant application. Also, do not identify any conviction for which the record has been judicially ordered sealed, expunged or statutorily eradicated, or any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed.

Connecticut Applicants: Applicants are not required to disclose the existence of any arrest, criminal charge, or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes. Criminal records subject to erasure under these sections are records pertaining to a finding of delinquency or the fact that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled (not prosecuted), a criminal charge for which the person was found not guilty, or a conviction for which the offender received an absolute pardon. Any person whose criminal records have been erased pursuant to these sections is deemed to have never been arrested within the meaning of the law as it applies to the particular proceedings that have been erased, and may so swear under oath.

District of Columbia: Do not identify convictions that are more than ten (10) years old.

Georgia Applicants: Do not identify any conviction that is considered a “first offender discharge.”

Hawaii Applicants: Do not answer this question at this time. You will only have to answer this question if you receive a conditional offer to serve as a volunteer. At that time you will be asked whether you have been convicted of a crime within the past ten (10) years.

Massachusetts Applicants: An applicant with a sealed record on file with the Commissioner of Probation may answer “no record” with respect to an inquiry herein relative to prior arrests, criminal court appearances, or convictions. In addition, an applicant may answer “no record” with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. Massachusetts applicants should not disclose information regarding first-time misdemeanor convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace. Finally, Massachusetts applicants should not disclose convictions for other misdemeanors where the date of conviction or the end of any period of incarceration was more than five years ago unless there have been subsequent convictions within those five years.

Ohio Applicants: Do not identify convictions that are more than ten (10) years old.

Washington Applicants: Do not identify any conviction that is more than ten (10) years old at the time of making this application.









Question - Not Required - Please indicate if you have more than one year of experience in the following areas:









Emergency Contact:





Information to Volunteer Applicants
(Read Carefully Before Signing)

You may be asked to sign an authorization for Susan G. Komen to fully investigate your suitability for volunteering (depending on the position and responsibilities) by obtaining information from your previous employers and/or other knowledgeable persons as to their firsthand experiences with you, and also, when deemed necessary, by obtaining reports from credit bureaus, credit agencies, or other consumer reporting agencies.  Under some circumstances, certain of such reports may be “consumer reports” or "investigative consumer reports" as to which, under the Fair Credit Reporting Act, you are entitled, upon your request in writing, to receive a complete and accurate disclosure of the nature and scope of the investigation requested by the Susan G. Komen.

I certify that I completed this volunteer application and that all the answers to the questions on this volunteer application and any attachments are to the best of my knowledge true and correct and that I have not knowingly withheld any pertinent facts or circumstances all of which are subject to validation.  I understand that any misrepresentation, false statement, or omission made by me with respect to the information contained in this volunteer application could disqualify me from consideration as a volunteer, or if selected as volunteer, result in the termination of my volunteer efforts from the Susan G. Komen.

If selected as a volunteer, I agree to comply with the rules and regulations of Susan G. Komen. 

I also understand that smoking is prohibited in all indoor areas of Susan G. Komen. 

   Please leave this field empty