Community Service Verification Form

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Community Service Verification Form
Form
Community Service is a vital part of a Centenary College education. Student volunteers are responsible for
fulfilling selected community service contracts assigned by the Community Service Office. Please fill out this form
& submit it to the Community Service or affiliated offices to receive credit for your work.
S
N
: __________________________________________ P
N
: __________________________________
TUDENT
AME
HONE
UMBER
S
A
: ________________________________ C
: ____________________ S
: _______ Z
: ___________
TUDENT
DDRESS
ITY
TATE
IP
C
ID: ______________________ E-M
A
: ___________________________________________________
ENTENARY
AIL
DDRESS
S
R
:
ERVICE
EQUIREMENT
P
.
LEASE CHECK THE BOX THAT BEST DESCRIBES THE REASON YOU ARE PERFORMING OR HAVE PERFORMED VOLUNTEER HOURS
(P
O
O
P
F
)
LEASE CHECK
NLY
NE
ER
ORM
G
R
S
J
S
C
R
RADUATION
EQUIREMENT
CHOLARSHIP
UDICIAL
ANCTION
LUB
EQUIREMENT
C
S
H
OMMUNITY
ERVICE
OURS
P
LEASE FILL OUT THE INFORMATION BELOW REGARDING YOUR COMMUNITY SERVICE HOURS
____________________________
_____________________
H
C
:
D
(S) C
:
OURS
OMPLETED
ATE
OMPLETED
O
/E
P
: _______________________________________________________________
RGANIZATION
VENT
ARTICIPATED IN
C
P
: ______________________________
C
P
N
: _____________________
ONTACT FOR
ROJECT
ONTACT
HONE
UMBER
C
S
: __________________________________________
ONTACT
IGNATURE
T
A
ERMS OF
GREEMENT
P
&
.
LEASE READ TERMS OF AGREEMENT
SIGN BELOW
By submitting this form you are acknowledging that you have completed the above mentioned community service hours. The hours
submitted via this form are subject to the discretion and approval of the Community Service office and any other party affiliated with
the office. The person or organization under which you performed these hours may be contacted to confirm the completion of hours.
S
N
: __________________________________
S
: ___________________________________________
TUDENT
AME
IGNATURE
F
O
U
O
:
OR
FFICE
SE
NLY
C
ID
H
C
H
R
ENTENARY
OURS
ONFIRMED
OURS
ECORDED
C
S
A
S
: _____________________________________________ D
:__________________
OMMUNITY
ERVICE
UTHORIZED
IGNATURE
ATE

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