Central Illinois Agency on Aging, Inc.

700 Hamilton Boulevard

Peoria, IL 61603

Telephone: (309) 674-2071 Toll Free: 1-877-777-2422

Fax: (309) 674-3639

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An independent, not-for-profit organization serving persons of all ages, incomes and abilities in Fulton, Marshall, Peoria, Stark, Tazewell and Woodford Counties.

Leadership Volunteer Application

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Day

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First Name

Last Name

Address

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Zip

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Currently Not Employed

Yes

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Address 2

Previous Employer 2

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Day

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Start Date

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Year

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Ending Title

Ending Date

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Position was:

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Position was:

Full-time

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Internship

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Duties (be specific)

Did you supervise others?

Yes

Did you supervise others?

Yes

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Leadership Volunteer Application