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Chat X Planet Moderator / Staff Application

APPLICATION FOR ROOM MODERATOR
Please fill out this application if you wish to be considered for a room moderator with ChatXPlanet.

Chat Nickname Used:
How Long Have You Been an Active Chatter At ChatXplanet?
First Name:
Last Name:
Valid Email Adress:
Re-Type Email Adress:
Date Of Birth:
If under 18, we will need your parents' or guardians' permission before acceptance.
Mailing Address:
City:
State / Province:
Zip / Postal Code
Country:
Telephone Number:
If under 18, name of parent(s) / Guardian(s) Contact Information:
We will contact them.
- Parent / Guardian Name
- Parent / Guardian Name
- Parent / Guardian Contact Number
- Parent / Guardian Contact Number
- Parent / Guardian Contact Email
- Parent / Guardian Contact Email
Room Your Eligible To Mod:
Days Of The Week You Can Mod: - Monday - Tuesday - Wednesday
check all that apply - Thursday - Friday Saturday - Sunday
Times You Would Be Available:
enter starting and ending time increments  
Do You Have Past Mod Experience?
If "Yes", At What Chat Site?
If "Yes", Are You Still An Active Mod?
If "Yes" to Active Mod, Where do You Mod?
Please Tell Us Why You Wish To Leave Current Mod Position:
(Maximum characters: 200)
You have characters left.
Are You Experienced With Chat Commands?
If Selected, Will You Follow All Guidelines and Rules?
Please Tell Us Why We Should Choose You To Be A Mod:
(Maximum characters: 200)
You have characters left.
Name of three References with Contact Information:
We will contact them.
- Reference 1 Name
- Reference 1 Contact Number
- Reference 1 Contact Email
- Reference 2 Name
- Reference 2 Contact Number
- Reference 2 Contact Email
- Reference 3 Name
- Reference 3 Contact Number
- Reference 3 Contact Email
Please Enter First and Last Name - (legal, digital signature)
By signing, you agree all information is true and accurate.
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Do you agree to follow the rules and enforce them?  
Submitting does not guarantee acceptance!  
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