RSVP VOLUNTEER HOURS SUBMISSION | United Way of Lackawanna, Wayne & Pike Counties

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Personal Information

Name

Address

Address 2

City

State

ZIP

Volunteer Hours

Date	Volunteer Site	# of hours volunteered
Date	Volunteer Site	# of volunteer hours
Date	Volunteer Site	# of volunteer hours
Date	Volunteer Site	# of volunteer hours
Date	Volunteer Site	# of volunteer hours
Date	Volunteer Site	# of volunteer hours
	Total Hours	Total 0

I hereby certify that the hours as listed above were incurred by me in connection with my volunteering for the United Way of Lackawanna and Wayne Counties' RSVP Program.

Volunteer Signature