Cdss Direct Service Verification Form

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CDSS Di
irect Ser
vice Veri
ification
Form
Th
his form shou
uld be use to v
verify and log
g direct servic
ce volunteer o
or work exper
rience for a
sin
ngle event or
a single seas
on within a p
program or org
ganization.
Name: Fi
irst: _______
__________
___________
__ M.I.: ___
___ Last: ___
__________
___________
____
Email: __
__________
___________
__________
___________
__________
___________
__________
_____
Phone: _
___________
___________
__________
___ CDSS #
: _________
___________
__________
____
Agency:
__________
__________
___________
__________
___________
__________
___________
____
Address:
_________
___________
___________
__________
___________
__________
___________
____
City: ___
___________
__________
___________
_ State: ____
_____ ZIP: _
__________
___________
____
Contact P
Person: ____
__________
___________
___________
___________
__________
___________
____
Email: __
__________
___________
__________
___________
__________
___________
__________
_____
Phone: _
___________
___________
__________
___________
__________
___________
__________
____
Type of d
direct servic
e: ________
___________
__________
___________
__________
___________
____
Date(s) o
of direct serv
vice: ______
___________
__________
___________
__________
___________
____
Length o
of direct serv
vice: _______
_ hours x __
______ days
s = _______
____ total ho
ours
Descripti
ion of Work
:
Signature
e of agency c
contact: ___
___________
__________
___________
__________
___________
____
Da
ate: _______
___________
_________
CDSS a
applicants sho
ould use and k
keep this form
m as a record o
of any direct
service activi
ity not associ
ated
wi
th a full or pa
art-time job. F
Full or part-tim
me work expe
eriences will
be verified on
n a separate
employmen
nt verification
n form.
Bla
azeSports Ame
erica, Certifie
ed Disability S
Sport Special
list Program
1670 Oa
akbrook Dr. S
Suite 331, Nor
rcross, GA 30
0093
Phone: 404
4-270-2000
FAX: 404-27
70-2039 Ema
ail: certificati
ion@blazespo

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