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22. Self-Certification: By signing this agreement, the Volunteer Station Representative certifies that the <br />volunteer station is a public or non-profit private organization, or a proprietary health care agency. <br />23. Amendments: This agreement may be amended at anytime by either party subject to approval by both <br />parties. <br />Does your agency require/allow: <br /> <br />1. APPLICATION:  YES X NO (Emergency Contact Only) <br /> <br />2. ORIENTATION PRIOR TO STARTING: X YES  NO <br /> <br />3. HEALTH SCREENING:  YES X NO <br /> <br />4. MANTOUX:  YES XNO <br /> <br />5. BACKGROUND CHECK:  YES  NO (Determined by Job Description) <br /> IF YES, STATION WILL COVER COST: X YES  NO FEE: $______ <br /> <br />6. SMOKING:  YES X NO <br /> <br />Please complete the following and sign below: <br /> <br />1. CURRENT SAFETY DOCUMENTATION ON FILE WITH RSVP: X YES  NO <br /> <br />2. # OF VETERANS SERVED ANNUALLY ____unknown____________ <br />3. # OF ACTIVE DUTY MILITARY AND MILITARY FAMILIES SERVED ANNUALLY _unknown __ <br /> <br />4. ANNUAL STATISTICS: ___23.697__________ (UNIT OF MEASURE IS __residents_________) <br /> <br />5. IS THE FACILITY WHERE RSVP VOLUNTEERS WILL BE SERVING ACCESSIBLE? <br />X YES  NO <br /> Please name any barriers to volunteer service: <br /> <br /> <br /> <br /> <br /> <br />(Continue to Partner Agreement Signature Page) <br />Agency Type <br /> <br />Select Agency Type <br />(Insert Checkmark) <br />Documentation Complete? <br />(Y or N) <br />Licensed Healthcare Facility <br />Government Entity X Y <br />Non-profit/501c3