<p> Volunteer Application DSRA Inc. Leadership Roles</p><p>Please save this form to your computer, complete the required information, and attach to an email to John Norris, [email protected] </p><p>For questions, please contact: Den Black, DSRA Board | Chair - 757-262-9925 / [email protected], or John Norris, DSRA Board | Secretary - 941-312-2120 / [email protected]</p><p>Name First Last</p><p>Address City / State / ZIP City State ZIP</p><p>Phone Home Cell</p><p>E-mail address Year started with GM/Delphi Year of Retirement/Separation Last/current Delphi plant Division City State</p><p>Previous experience (e.g. Finance, HR, Management, other)</p><p>My Résumé is attached</p><p>Yes No Specialized experience or contacts (e.g. Legal, Legislative, Close Contact with your Senator or House Representative, other) Role you would like to fill for DSRA Best time to reach you</p><p>DSRA Inc., PO Box 64, Carmel IN 46082-0064 www.DelphiSalariedRetirees.org Rev002 Updated 8/19/2012 Any limitations or additional information</p><p>Were you ever convicted of, pleaded no contest to, or placed on probation for a felony or are you currently on probation; or have you been involved in a felony or misdemeanor involving the process of a deferred adjudication? If "yes", please provide details. Yes No</p><p>As a volunteer for DSRA Inc., I understand that I have agreed to volunteer my time and talents toward accomplishing the goals of the DSRA Inc. organization. I also understand and agree that DSRA Inc., its members, leadership, and employees are not responsible for my welfare or behavior while I am participating in any volunteer duties on behalf of the organization. DSRA Inc. assumes no responsibility or liability for my actions, or for those of any other participant. I do, therefore, release, acquit, satisfy and forever discharge DSRA Inc., its members, leadership, and employees from any and all injuries, expenses, liabilities whatsoever, incurred as a result of my participation as a volunteer, including, but not limited to any negligence or any other act omission on the part of DSRA Inc., its members, leadership, or employees. I have read, understand and agree to the above stated material and also consent to the use of my name and/or likeness in materials provided to DSRA Inc. members and the public, including web pages. Certification and Authorization: I certify that the information provided in this Volunteer Application is true, correct and complete. I authorize verification of all statements contained in this application. </p><p>Signature or typed name Date (mm/dd/yyyy)</p><p>DSRA INC. RESERVES THE RIGHT TO CONDUCT BACKGROUND CHECKS ON ALL STAFF & VOLUNTEERS.</p><p>When completed, please send this form to: JOHN NORRIS, [email protected]</p><p>DSRA Inc., PO Box 64, Carmel IN 46082-0064 www.DelphiSalariedRetirees.org Rev002 Updated 8/19/2012 </p>