AMERICORPSMEMBER APPLICATION
YourWorld.YourChanceToMakeItBetter.
ThousandsofOpportunitiesAwait.
ApplyToday!
TolearnmoreaboutAmeriCorpsandeachoftheprograms,visitAmeriCorps.gov.Orcallthe
AmeriCorpshotlineat1-800-942-2677(TTY1-800-833-3722).
PrintoutandusethisapplicationORgototheMyAmeriCorpsPortalandapplyonline
PLEASEREADTHISINFORMATIONBEFORECOMPLETINGTHEAPPLICATION
•ThisapplicationmaybeusedtoapplyforAmeriCorpsState andNational,AmeriCorps VISTA, AmeriCorps NCCC and FEMA Corps programs. However,ifyou areapplyingto anAmeriCorpsStateor Nationalprogram,youshouldfirstcheck withtheprogramtosee ifitrequiresadditionalor alternateforms.Todeterminespecific applicationrequirements,visittheAmeriCorpswebsiteatAmeriCorps.govorcall1-800-942-2677.
•If you're applying to more thanone AmeriCorps program, completethe entire applicationexcept forquestion11andthefinal"Certification"Section.Makeonecopyoftheapplicationforeachprogram. Then,answerquestion11andsigneachcopyseparatelybeforemailing.
•Youmayuseadditionalsheetsofpapertoprovidemoredetailedinformationthatwillnotfitonthisapplicationform.Encloseeverythinginthefinal applicationpacketthat you submit.
•Tworeferenceformsareenclosedinthispacket.Theyareanimportantpartofyourapplicationandmust besubmittedwithyourapplication. Yourapplicationcannotbe consideredwithoutreferences.Ifyouareapplyingtomultipleprogramsandusingthesamepersonasareference,pleaseremindthemto make multiple copies after completingthereference form.
•Makeacopyofyourapplicationforyourpersonalrecordsbeforeyousenditin.
•Send your application to the right place. Please refer to the back cover for instructions.
•This publication is available upon request in alternative formats for people with disabilities. Call1-800-942-2677;TTY:1-800-833-3722.
Publicreportingburdenforthiscollectionofinformationisestimatedtoaverage1.25hourspersubmission,includingreviewinginstructions,gatheringandmaintainingthedataneeded,andcompletingtheform.CommentsontheburdenorcontentofthisinstrumentmaybesenttotheCorporationforNationalandCommunityService,1201NewYorkAvenue,NW,Washington,DC 20525.TheCorporation informspeoplewho mayrespondto thiscollection ofinformationthat theyarenotrequired torespond tothe collectionof informationunless theOMB controlnumberand expirationdate displayedonpage1arecurrentandvalid.(See5C.F.R.1320.5(b)(2)(i).)
OMB#3045-0054Expires12/31/2018
PERSONAL PROFILE
1.NAME:
LASTFIRSTMIDDLE
2.AmeriCorpsmembersmustbeaUnitedStatescitizen,U.S.nationalorlawfulpermanentresident.
AreyouaUnitedStatescitizen,national,orlawfulpermanentresidentalien?■ Yes■ No
IfyouarealawfulpermanentresidentalienandyoureceivedyourcardafterJanuary1987,whatisyourregistrationnumber andcardexpirationdate?
3.FINALFOURNUMBERSOFSOCIALSECURITYNUMBER:
Youwillprovideyourfullsocialsecuritynumberlaterintheprocess.
4.DATEOFBIRTH:
MONTH/DAY/YEAR
5.PLACEOFBIRTH:
CITY/STATE/COUNTRY
6.GENDER:■ Male■ Female
7.Earliestdateyouareavailabletobeginservice:
MONTH/DAY/YEAR
8.CURRENTADDRESS:Allinformationwillbesenttothisaddressunlessyounotifyusofachange.
NUMBERANDSTREET(IFPOSSIBLE,INCLUDEANUMBERANDSTREETADDRESSWHENUSINGAP.O.BOX)
CITYSTATEZIPCODE
HomePhone()
WorkPhone()
CellPhone()
9.Areyoumovingwithinthenextsixmonths?■ Yes ■ No Ifyes,when*?
*Pleasenotifyusofnewaddressattimeofmove.MONTH/DAY/YEAR
10.EMERGENCYCONTACT/PERMANENTADDRESS(ifdifferentthanabove):Pleasegivethenameandaddressofapersonthroughwhomyoucanalwaysbereached:
Name:
FIRSTLAST
Relationship:
NUMBERANDSTREET(IFPOSSIBLE,INCLUDEANUMBERANDSTREETADDRESSWHENUSINGAP.O.BOX)
CITYSTATEZIPCODE
HomePhone()
WorkPhone()
CellPhone()
11.WhichAmeriCorpsprogramareyouapplyingto?Checkonlyone.IfyouareapplyingtomorethanoneAmeriCorpsprogram,fillthisinafteryoucopyyourapplication.Entertheprograminformationoneachapplication.
■AmeriCorpsStateandNational
Memberswho areover theageof17 serveeitherinteamsorindividuallythroughnationalandcommunity-basedprivate andpublicorganizations.Membershelpsolvecommunityproblems throughdirect andindirect servicein the areasof disaster services, economic opportunity,education, environmental stewardship, healthy futures, and humanneeds,such veterans and military families.
ProgramName
ProgramAddress
■AmeriCorpsVISTA(VolunteersinServicetoAmerica)
Memberswhoareatleast18yearsoldprovideindirectservicethroughprivateorganizationsandpublic nonprofitagencies, addressing issuesrelated to poverty—suchas financial security,homelessnessandhelping,disadvantagedyouth,communitydevelopment,andemployment—bydevelopingandmobilizingresourcesthatcreatelong-termsustainablebenefitsatacommunitylevel.
ProgramName
ProgramAddress
■AmeriCorps NCCC (National Civilian CommunityCorps)
Membersages18to24serveina10-monthteam-basedresidentialprogramtocompleteavarietyofserviceprojectsintheareasofeducation,disasterservices,theenvironment,andotherunmetneeds.Membersoftentraveltoprojectsthroughouttheirregion.
■FallClass(September/Octoberstartdates)■ WinterClass (Januarystartdates)
■FEMA Corps a branch of AmeriCorps National Civilian CommunityCorps
Membersages18to24serveina10-monthteam-basedresidentialprogramtocompleteprojects in disaster preparedness, response, and recovery.Membersoftentraveltoprojectsthroughouttheircountry.
■FallClass(September/Octoberstartdates)■ WinterClass (Januarystartdates)
EDUCATION
12.Checkthehighestlevelofeducationthatyouwillhavecompletedbythetimeyou areplanningtoserveinAmeriCorps.(Checkonlyone.)
■ / Somehighschool / ■ / Associate'sdegree / ■Graduatedegree■ / HighschooldiplomaorGED / ■ / Somecollege / ■Other(pleasespecify):
■ / Technical school/Apprenticeship / ■ / Bachelor'sdegree
13.Listallschoolsafterhighschoolthatyouhaveattended,includingtradeortechnicalschools,militarytrainingandemploymenttrainingprograms.
A.
B.
C.
D.
COMMUNITYSERVICE(Previousserviceisnotalwaysarequirement.)
14.Describehowyouhavereachedouttohelpothersand/orhowyouhavebeeninvolvedinyourown community.Explain why you decided to serve or get involved,and what you received in return-that is,whatyoulearnedorhowitmadeyoufeel.Thinkinbroadterms.Listyourmostrecentactivityfirst. Attachaseparatesheetofpaperifyouneedmorespace.(Yourinvolvementcouldincludeservinginneighborhood,school,religious,social,professional,orothervolunteergroups;helpingoutwith communityserviceprojects;orparticipatinginlessformalactivities.)
A.DATESOFINVOLVEMENT:From:
To:Hourspermo.:
MONTH/YEARMONTH/YEAR
OrganizationName:Location:Phone:
DescriptionofInvolvement:
B.DATESOFINVOLVEMENT:From:
To:Hourspermo.:
MONTH/YEARMONTH/YEAR
OrganizationName:Location:Phone:
DescriptionofInvolvement:
MOTIVATIONALSTATEMENT
15.WewouldliketounderstandmoreaboutyouandyourreasonsforapplyingtoAmeriCorps.Takeafewminutesandconsiderthoseexperienceswhichhavemadeyouthepersonyouaretoday.Pleasesharewithus oneofthese experiencesandhow it sparked yourinterestin community service.If you needadditionalspace,attachaseparatepieceofpaperandlimityourtotalresponseto500words.
EMPLOYMENT
16.Beginningwiththemostcurrentormostrecentposition,listandbrieflydescribethelastfourpositionsyouhaveheld or your lasttenyears of employment.Begin withthe current or mostrecent and gobacktenyears.Includeself-employment,internships/fellowships,homemanagement,andfull-orpart-timepaidorunpaidworkexperience.(Youmayattacharesumeinsteadifitaddressestheinformationrequestedbelow.)
NAMEANDADDRESSOFEMPLOYER / DATES / JOBTITLEANDDUTIESA.Organization,City/State:
Supervisor:Phoneandemail / From:/
MO./YR.
To:/
MO./YR.
Hrs./week: / Title: Duties:
Reasonforleaving:
B.Organization,City/State:
Supervisor:Phoneandemail / From:/
MO./YR.
To:/
MO./YR.
Hrs./week: / Title: Duties:
Reasonforleaving:
NAMEANDADDRESSOFEMPLOYER / DATES / JOBTITLEANDDUTIES
C.Organization,City/State:
Supervisor:Phoneandemail / From:/
MO./YR.
To:/
MO./YR.
Hrs./week: / Title: Duties:
Reasonforleaving:
D.Organization,City/State:
Supervisor:Phoneandemail / From:/
MO./YR.
To:/
MO./YR.
Hrs./week: / Title: Duties:
Reasonforleaving:
17.ExplainanyperiodoftimegreaterthansixmonthsnotaccountedforbyAmeriCorps,PeaceCorps,work,school, ormilitary service.Or, explainwhy youhave noemploymenthistory.
SKILLSANDEXPERIENCE
18. ListedbelowareskillareasthatsomeprogramsfindusefulandmayseekinAmeriCorpsapplicants.Indicatetheskillareasinwhichyouhavehadtrainingorexperience,includingvolunteerorcommunityserviceexperience,andindicatehowyougainedthoseskills.
EXAMPLE:
✓■ PublicSpeaking–ClubPresident
■ArchitecturalPlanning
■Business/Entrepreneur
■Communications
■Community Org./Development
■Computers/Technology
■ConflictResolution
■Counseling
■Education
■FineArts/Crafts
■FirstAid
■Fundraising/GrantWriting
■Law
■Leadership
■Medicine
■PublicHealth
■PublicSpeaking
■Recruitment
■Teaching/Tutoring
■Trade/Construction
■Writing/Editing
■YouthDevelopment
■Other(specify):
19.Doyouknoworhaveyoustudiedanylanguage(s)otherthanEnglish? ■ Yes ■ No
Language(s):
Numberofyearsstudiedorspoken:
SpeakingAbility:■ / Poor / ■ / Fair / ■ / Good / ■Excellent
WritingAbility:■ / Poor / ■ / Fair / ■ / Good / ■Excellent
20.Inthespacebeloworonaseparatesheetofpaper,provideanyadditionalskillsandexperiencethatmaybehelpfulinevaluatingyourapplication,includingotherlanguagesspoken.
21.Do you have a valid driver’s license?■Yes ■NoLicense#State(ThisisarequirementforsomeAmeriCorpsprograms,butnotall.)
CRIMINALHISTORY
TheAmeriCorpsapplicationprocessrequiresacriminalhistory checktoensurethatcommunitymemberswithwhomweworkareprotected,particularlychildren,individualswithdisabilities,andindividualsover60yearsold.
Wewill investigatefor past sexual offenses and violentcrimes, orcrimes thatwouldhaveadirect bearingonyour service.
ThisbackgroundcheckwillentailoursearchoftheNationalSexOffendersRegistryandanFBIcriminalhistory check,whichwillrequireyour beingfingerprintedatPre-ServiceOrientation.
Youwillnotbepermittedtoserveorworkwithchildren,individualswithdisabilities,orindividualsover60yearsofage,withoutsupervisionuntilthehistorycheckiscompleteandyou arecleared.Thereviewprocessisnotlengthy,andnormallyiscompletedwithinweeks.
Answerthefollowingquestionsfully.Existenceofacriminalconvictionorjuvenileadjudicationmayormaynot,dependingonthecircumstances,disqualifyyoufromconsideration.However,anyintentionalmisrepresentationoromissionwilldisqualifyyou.Donotincludeminortrafficviolations.
■IallowtheAmeriCorpsprogramtocompletean NSOPW checkandcriminalbackgroundcheck
22.Haveyoueverbeenconvictedasanadult,oradjudicatedasajuvenileoffender,ofanycriminaloffensebyeitheracivilianormilitarycourt,otherthanminortrafficviolations? ■ Yes ■ No
Areyoucurrentlyfacingchargesforanyoffenseoronprobationorparole?■Yes ■NoIfno,skipto“Certification”below.
Ifyouanswered“yes”toanyofthequestionsabove,pleaseprovidethefollowinginformation:
Date:
Place:
MONTH/DAY/YEARCITYSTATE
Charge: ActionTaken: Court,Probation,orParoleOfficer: Phone:( ) Name: Address:
NUMBERANDSTREET
CITYSTATEZIPCODE
Youmayattachanyadditionalinformationorexplanationonaseparatesheet.
CERTIFICATION
Ifyouchoosetosubmitapaperapplication,yourapplicationmustbecertifiedwithyouroriginalsignaturein ink. Ifyou are applying tomore than one AmeriCorpsprogram, make a copyfor each program thatyou’re applying to first, and then sign each one.
Bysigningthisapplication,orbysubmittingitelectronicallyifapplyingon-line,Icertifythatallofthestatementsmadeinthisapplicationaretrue,correct,andcomplete,tothebestofmyknowledge,andaremadeingoodfaith.Misinformationoromissionofinformationcouldresultindisqualificationor termination as an AmeriCorps member. IfI am selected for participation in someAmeriCorps programs, includingAmeriCorpsNCCC,Imayberequiredtosubmittoaphysicalexamination,includingdrugoralcoholtesting.Backgroundandsecuritychecksmayalsobeconductedbysomeprograms.
PUBLICBURDENSTATEMENT:Publicreportingburdenforthiscollectionofinformationisestimatedtoaverage1.5hourspersubmission, includingreviewinginstructions,gatheringandmaintainingthedataneeded,andcompletingtheform.Commentsontheburdenor contentofthisinstrumentmaybesenttotheCorporationforNationalandCommunityService,Attn:AmyBorgstrom,1201NewYorkAvenue,NW,Washington,D.C. 20525. TheCorporation informs peoplewho may respond tothis collection ofinformation that they arenot required torespondtothecollectionofinformationunlesstheOMBcontrolnumberandexpirationdatedisplayedonpage1arecurrentandvalid.(See5C.F.R.1320.5(b)(2)(i).)
PRIVACYACTNOTICE:ThePrivacyActof1974(5U.S.C§552a)requiresthatthefollowingnoticebeprovidedtoyou:Theauthorityforcollectinginformation fromyou inthis application iscontained in42 U.S.C12592 and 12615of theNational and CommunityServiceActof 1990asamended,and42U.S.C4953oftheDomestic VolunteerServiceActof1973asamended.Youareadvisedthatsubmissionoftheinformationisentirelyvoluntary,buttherequestedinformationisrequiredinorderforyoutoparticipateinAmeriCorpsprograms.Theprincipalpurposeforrequestingthis personalinformationis toprocessyour applicationforacceptanceinto anAmeriCorpsprogram, andforother generalroutinepurposesassociatedwithyourparticipationinanAmeriCorpsprogram.Theseroutinepurposesmayincludedisclosureoftheinformationtofederal,state,orlocalagenciespursuanttolawfullyauthorizedrequests,topresentandformeremployers,referencesprovidedbyyou inyourapplication,andeducationalinstitutions,forthepurposeofverifyingtheinformationprovidedbyyouinyourapplication. Theinformationmaybesharedwithotheragencies,suchastheSocialSecurityAdministration,throughcomputermatchingagreementsforthepurposeofverifyingidentityandcitizenshipstatusinformationprovidedbyyouinyourapplication. Insomeprograms,theinformationmayalsobepro-videdtofederal,state,andlocallawenforcementagenciestodeterminetheexistenceofanypriorcriminalconvictions.TheinformationmayalsobeprovidedtoappropriatefederalagenciesandDepartmentcontractorsthathaveaneedtoknowtheinformationforthepurposeofassistingtheDepartment’seffortstorespondtoasuspectedorconfirmedbreachofthesecurityorconfidentialityorinformationmaintainedinthissystemofrecords,andtheinformationdisclosedisrelevantandunnecessaryfortheassistance. Theinformationwillnototherwisebedisclosed to entities outside of AmeriCorps and the Corporation for Nationaland Community Service without prior written permission.
SIGNATUREDATE
PrintName:
ForParentorGuardianofApplicantsUnder18YearsofAge:IhavereviewedthisapplicationandIauthorizemyson/daughter/legalwardtoapplytoAmeriCorps.
SIGNATUREDATE
NAME:
RELATION:
PHONE:()
ADDRESS:(IFP.O.BOX,ALSOGIVENUMBERANDSTREET) CITY STATE ZIPCODE
CorporationforNationalandCommunityServiceprogramsareavailabletoallwithoutregardtorace,color,nationalorigin,disability,age,gender,sexualorientation,religion,politicalaffiliation,orother non-meritfactors.Anyonebelieving heor she has beensubjectedtodiscriminationon thesegroundsby theCorporationfor National andCommunity Service,AmeriCorps,or oneofits granteesmaycontactourOfficeofCivilRightsandInclusivenessat(202)606-7503oremailat.
REFERENCEFORM
TOTHEAPPLICANT:
Pleasecomplete theinformationbelowand givethisformto eachofyourreferences. Select peoplewhoknowyouwelland who are familiar with your personal background, education, employment, and/or professional skills.Youshouldnot askafamilymember, peer,classmate,co-worker,orfriendto serveasa reference.Consideraskingworksupervisors, clergy,teachers, counselors,coaches, orsomeoneelse familiar with your motivationand communityinvolvement.
Yourreferenceshouldcompletethisform, sealitin an envelope,signhisorhernameacross the sealon theoutsideof theenvelope,andreturnittoyoutoincludewiththeapplicationyousend toAmeriCorps.
Applicant’sName:
LASTFIRSTMIDDLE
Address:
(IFP.O.BOX,ALSOGIVENUMBERANDSTREET)CITYSTATEZIPCODE
HomePhone:()
WorkPhone:()
INDICATETHEPROGRAMTHATYOUAREAPPLYINGTO(checkonlyone):
■AmeriCorpsStateandNational:
Programname: Programaddress:
■AmeriCorpsVISTA
Programname: Programaddress:
■AmeriCorpsNCCC or FEMA Corps
TOTHEPERSONALREFERENCE:
AmeriCorpsengagesmorethan70,000Americansayearinresults-drivenservicesponsoredbythousandsoflocalandnationalnonprofits,publicagencies,andfaith-basedandcommunityorganizations.AmeriCorpsmembershelpcommunities meetcritical challenges in the areasof disaster services, economic opportunity, education, environment, and human needs, such as serving veterans and military families.Inreturn,AmeriCorpsmembersmayearnaSegalAmeriCorpsEducationAwardthathelpspayforcollegeorpaybackstudentloans.
ThepersonnamedaboveisapplyingtobeanAmeriCorpsmember.Theapplicanthasindicatedthatyouwouldbeableto evaluatehisorherqualificationsandprovideuswithacandidrecommendation.
ThesuccessofAmeriCorpslargelydependsuponanappropriatematchbetweenprogramsandmembers.Considerablevalueisplacedonpersonalreferencesduringtheapplicationreviewandselectionprocess.Yourinputis greatly appreciated.
NameofReference:
LASTFIRSTMIDDLE
Position/Title: Organization/Institution: Address:
(IFP.O.BOX,ALSOGIVENUMBERANDSTREET)CITYSTATEZIPCODE
HomePhone:()
WorkPhone()E-mail:
KNOWLEDGEOFTHEAPPLICANT
Howlonghaveyouknowntheapplicant? Years:
Months:
Inwhatcapacityhaveyouknowntheapplicant?
■JobSupervisor/Employer■ HighSchoolTeacher■ Clergy
■VolunteerSupervisor■ CollegeInstructor■ Coach
■Other(specify):
Pleasedescribethesituationinwhichyouknowtheapplicant.
WORKPERFORMANCE
1.Please comment on such qualitiesas the applicant'slevel of dependability, initiative,and ability to work withminimalsupervisionandasamemberofateam.
2.Inyourjudgment,howcompetentisthisapplicant,asdemonstratedbyworkinthecommunity,inschool,onthejob,orinapositionofresponsibility?Pleasecheckone.
■Outstandingperformance
■Aboveaverageperformance
■Satisfactory
■Belowaverageperformance
■Unsatisfactoryperformance
RELATIONSHIPSWITHOTHERPEOPLE
3.AmeriCorpsmembersmustserveandcommunicatewithpeopleofvariedcultural,economic,educational,racial,andreligious backgrounds. Pleasecommentbrieflyonthe applicant'srelationshipswithothersandabilitytoworkasamemberofateam.
EMOTIONALMATURITY
4.Please commentontheapplicant'sability toadaptandworkunder difficultandchangingconditions.
ADDITIONALCOMMENTSANDSUPPORTINGINFORMATION
5.If you wish, use additional paper to explain any of your ratings,and anything else about this
applicantthatyou feelis relevanttoservinginAmeriCorps-suchas theapplicant'sdesireto serveothers,maturity,workethic,flexibility,anddependability.Explainanyreservationsthatyouhaveregarding theapplicant's participationin theAmeriCorps programto whichhe orshe hasapplied.
OVERALLRECOMMENDATION
6.Whatisyouroverallrecommendation?
■IrecommendtheapplicantforAmeriCorpsservice.
■Ihavesomereservations,butIbelievetheapplicantwillsucceedinservingwithAmeriCorps.
■I do not recommend this applicant for AmeriCorps service.
CONFIDENTIALITYSTATEMENT
■IAUTHORIZEtheprogramand/ortheCorporationforNationalandCommunityServicetoidentifymeasthesourceofthis reference andto releaseacopyofthis referenceinitsentiretyuponrequestto theapplicant.
■IDONOTauthorizetheprogramand/ortheCorporationforNationalandCommunityServicetoidentifymeasthe source of this reference, nor do Iauthorize the release ofa copy of thisreference in its entirety to theapplicant.
YourSignature:
PLEASERETURNTHISFORM,INANENVELOPESIGNEDACROSSTHESEAL,DIRECTLYTOTHEAPPLICANT.
REFERENCEFORM
TOTHEAPPLICANT:
Pleasecomplete theinformationbelowand givethisformto eachofyourreferences. Select peoplewhoknowyouwelland who are familiar with your personal background, education, employment, and/or professional skills.Youshouldnot askafamilymember, peer,classmate,co-worker,orfriendto serveasa reference.Consideraskingworksupervisors, clergy,teachers, counselors,coaches, orsomeoneelse familiar with your motivationand communityinvolvement.
Yourreferenceshouldcompletethisform, sealitin an envelope,signhisorhernameacross the sealon theoutsideof theenvelope,andreturnittoyoutoincludewiththeapplicationyousend toAmeriCorps.
Applicant’sName:
LASTFIRSTMIDDLE
Address:
(IFP.O.BOX,ALSOGIVENUMBERANDSTREET)CITYSTATEZIPCODE
HomePhone:()
WorkPhone:()
INDICATETHEPROGRAMTHATYOUAREAPPLYINGTO(checkonlyone):
■AmeriCorpsStateandNational:
Programname: Programaddress:
■AmeriCorpsVISTA
Programname: Programaddress:
■AmeriCorpsNCCC or FEMA Corps
TOTHEPERSONALREFERENCE:
AmeriCorpsengagesmorethan70,000Americansayearinresults-drivenservicesponsoredbythousandsoflocalandnationalnonprofits,publicagencies,andfaith-basedandcommunityorganizations.AmeriCorpsmembershelpcommunities meetcritical challenges in the areasofdisaster services, economic opportunity, education, environment, and human needs, such as serving veterans and military families.Inreturn,AmeriCorpsmembersmayearnaSegalAmeriCorpsEducationAwardthathelpspayforcollegeorpaybackstudentloans.
ThepersonnamedaboveisapplyingtobeanAmeriCorpsmember.Theapplicanthasindicatedthatyouwouldbeableto evaluatehisorherqualificationsandprovideuswithacandidrecommendation.
ThesuccessofAmeriCorpslargelydependsuponanappropriatematchbetweenprogramsandmembers.Considerablevalueisplacedonpersonalreferencesduringtheapplicationreviewandselectionprocess.Yourinputis greatly appreciated.
NameofReference:
LASTFIRSTMIDDLE
Position/Title: Organization/Institution: Address:
(IFP.O.BOX,ALSOGIVENUMBERANDSTREET)CITYSTATEZIPCODE
HomePhone:()
WorkPhone()E-mail:
KNOWLEDGEOFTHEAPPLICANT
Howlonghaveyouknowntheapplicant? Years:
Months:
Inwhatcapacityhaveyouknowntheapplicant?
■Job Supervisor/Employer■ HighSchoolTeacher■ Clergy
■Volunteer Supervisor■ CollegeInstructor■ Coach
■Other(specify):
Pleasedescribethesituationinwhichyouknowtheapplicant.
WORKPERFORMANCE
1.Please comment on such qualitiesas the applicant'slevel of dependability, initiative,and ability to work withminimalsupervisionandasamemberofateam.
2.Inyourjudgment,howcompetentisthisapplicant,asdemonstratedbyworkinthecommunity,inschool,onthejob,orinapositionofresponsibility?Pleasecheckone.
■Outstandingperformance
■Aboveaverageperformance
■Satisfactory
■Belowaverageperformance
■Unsatisfactoryperformance
RELATIONSHIPSWITHOTHERPEOPLE
3.AmeriCorpsmembersmustserveandcommunicatewithpeopleofvariedcultural,economic,educational,racial,andreligious backgrounds. Pleasecommentbrieflyonthe applicant'srelationshipswithothersandabilitytoworkasamemberofateam.
EMOTIONAL MATURITY
4.Please commentontheapplicant'sability toadaptandworkunder difficultandchangingconditions.
ADDITIONALCOMMENTSANDSUPPORTINGINFORMATION
5.If you wish, use additional paper to explain any of your ratings,and anything else about this
applicantthatyou feelis relevanttoservinginAmeriCorps-suchas theapplicant'sdesireto serveothers,maturity,workethic,flexibility,anddependability.Explainanyreservationsthatyouhaveregarding theapplicant's participationin theAmeriCorps programto whichhe orshe hasapplied.
OVERALL RECOMMENDATION
6.Whatisyouroverallrecommendation?
■IrecommendtheapplicantforAmeriCorpsservice.
■Ihavesomereservations,butIbelievetheapplicantwillsucceedinservingwithAmeriCorps.
■I do not recommend this applicant for AmeriCorps service.
CONFIDENTIALITY STATEMENT
■IAUTHORIZEtheprogramand/ortheCorporationforNationalandCommunityServicetoidentifymeasthesourceofthis reference andto releaseacopyofthis referenceinitsentiretyuponrequestto theapplicant.
■IDONOTauthorizetheprogramand/ortheCorporationforNationalandCommunityServicetoidentifymeasthe source of this reference, nor do Iauthorize the release ofa copy of thisreference in its entirety to theapplicant.
YourSignature:
PLEASERETURNTHISFORM,INANENVELOPESIGNEDACROSSTHESEAL,DIRECTLYTOTHEAPPLICANT.
AMERICORPSAPPLICATION
OPTIONALINFORMATION
HOWDIDYOUHEARABOUTAMERICORPS?Youmaycheckmorethanone.
■AmeriCorps representative
(Service/careerfair,conference,informationsession)
■ArmedForces
■CurrentorformerAmeriCorpsmember
■Friend/Relative
■Internet/Listserv/E-mail
■Newspaper/Magazine advertisement
■Otherserviceorganization
■Radiostory
■Television advertisement
■Posteratschool
■Collegeguidanceoffice/Placementoffice
■DepartmentofEducation
■Highschoolguidancecounselor
■Newspaper/Magazine article
■PeaceCorps
■Radio advertisement
■Received information in the mail
■Televisionnewsstory
■Other(specify)
WHATISYOURETHNICITY?(optional)■ Hispanic or Latino■ NotHispanicorLatino
WHATISYOURRACE?(optional)Markoneormore:
■AmericanIndianorAlaskaNative.ApersonhavingoriginsinanyoftheoriginalpeoplesofNorth andSouthAmerica(includingCentralAmerica)andwhomaintainstribalaffiliationorcommunityattachment.
■Asian. ApersonhavingoriginsinanyoftheoriginalpeoplesoftheFarEast,SoutheastAsia,orthe
Indiansubcontinentincluding,forexample,Cambodia,China,India,Japan,Korea,Malaysia,Pakistan,thePhilippineIslands,Thailand,andVietnam.
■BlackorAfricanAmerican.ApersonhavingoriginsinanyoftheblackracialgroupsofAfrica.
■NativeHawaiianorOtherPacificIslander.ApersonhavingoriginsinanyoftheoriginalpeoplesofHawaii,Guam,Samoa,orotherPacificIslands.
■White. Aperson havingorigins inany ofthe originalpeoples ofEurope, the MiddleEast, orNorth
Africa.
AMERICORPSAPPLICATION
WHERETOSENDYOURAPPLICATION
Pleasesendyourapplicationdirectlyto theAmeriCorpsprogram whereyouwishto serve.Toget theaddress for the AmeriCorps program whereyou wish to serve, orto apply online, visit the AmeriCorpswebsiteatAmeriCorps.gov.If you don'thave Internetaccess, youcan still get program information orapplybycalling1-800-942-2677.
Printout and usethisapplication ORgoto theMyAmeriCorpsPortal andapplyonline
IfyouareapplyingtoAmeriCorpsNCCC or FEMA Corps,send yourapplicationto:
AmeriCorpsNCCC
1201NewYorkAvenue,N.W.Washington,DC20525
QUESTIONS?CALL 1-800-942-2677
OR (TTY) 1-800-833-3722
YourWorld.YourChanceToMakeItBetter.
AmeriCorps.gov