SERV Non-Profit Request Form

Requestor’s Information                                          

Date________________

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Name                                                                                       

__________________________      ___________________________

Primary phone number                  E-mail address

Type of Volunteer Service Leave

c   Education                                          c  Mentoring                  

c   Human Service                                   c  Health                          

c Environmental                                    c Public Safety

Non-Profit Information

Please list the name of the organization staff member that we may contact regarding this request:

____________________________________________          ____________________________

Organization Name                                                                     Website         

 ____________________________________________          ____________________________   

Name of volunteer coordinator                                                   Phone number

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Address

___________________________________________________________________                                                                  

City, State, Zip Code  

Comments: ___________________________________________________________________

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